CN113301907A

CN113301907A - Drug for treating and/or improving sepsis associated with blood coagulation disorder

Info

Publication number: CN113301907A
Application number: CN201980069133.5A
Authority: CN
Inventors: 松木修; 田中康介; 田中理砂
Original assignee: Asahi Kasei Pharma Corp
Current assignee: Asahi Kasei Pharma Corp
Priority date: 2018-10-22
Filing date: 2019-08-01
Publication date: 2021-08-24
Also published as: WO2020084853A1; BR112021007460A2; CA3177374A1; AU2019366008B2; US20230165941A1; JPWO2020084853A1; EP3871684B1; JP2023016990A; MX2021004511A; EP3871684A4; KR20210060574A; JP7237085B2; IL282378A; AU2019366008A1; CA3116686A1; EP3871684A1

Abstract

The invention relates to a medicament for the treatment and/or amelioration of patients with sepsis, comprising thrombomodulin as active ingredient, characterized in that the medicament is intended for administration to such patients whose value of the International Normalized Ratio (INR) immediately before administration is greater than 1.4.

Description

Drug for treating and/or improving sepsis associated with blood coagulation disorder

Technical Field

The present invention relates to a drug for treating and/or improving sepsis accompanied by blood coagulation disorders.

Background

Sepsis is Systemic Inflammatory Response Syndrome (SIRS) caused by infection. That is, it is defined as satisfying the SIRS program ((1) body temperature) in addition to the presence of infection>38 ℃ or<36 ℃ and (2) heart rate>90/min, (3) respiratory rate>20/min or PaCO₂<32torr, (4) white blood cell count>12,000/. mu.L or<4000/. mu.L or immature leukocytes>10%) of 2 or more. Although the presence of bacterial cells in blood has been emphasized in the past (bacteremia), this definition does not necessarily require that blood culture be positive. In sepsis, a state in which organ dysfunction, organ hypoperfusion, or hypotension is present is called severe sepsis (severe septis). Organ hypoperfusion or perfusion abnormalities include lactic acidosis, oliguria, confusion, and the like. In severe sepsis, hypotension continues even when a sufficient infusion load is applied, and is called septic shock (non-patent document 1). The circulatory failure found in these pathological conditions is thought to be caused by dysfunction of the sympathetic nervous system or mediators released from neutrophils and the like, and organ dysfunction is thought to be caused by dysbolism of tissue oxygen (malignant hypoxia).

On the other hand, thrombomodulin is known to be a substance that specifically binds to thrombin, has a function of inhibiting the blood coagulation activity of thrombin and remarkably promoting the protein C activation ability of thrombin, and is known to have a potent blood coagulation inhibitory action. Thrombomodulin is known to prolong the time of coagulation by thrombin and to inhibit platelet aggregation by thrombin. Protein C is a vitamin K-dependent protein that plays an important role in the blood coagulation and fibrinolysis system, and is activated by the action of thrombin to become activated protein C. It is known that this activated protein C inactivates factor V and factor VIII, which are active forms of coagulation system factors, in vivo and is involved in the production of plasminogen activator having thrombolytic activity (non-patent document 2). Therefore, thrombomodulin promotes activation of protein C by this thrombin, is useful as an anticoagulant or thrombolytic agent, and there has been a report on animal experiments in which thrombomodulin is effective for treatment and prevention of diseases accompanied by hypercoagulability (non-patent document 3).

Conventionally, thrombomodulin has been found and obtained as a glycoprotein expressed on vascular endothelial cells of various animal species including humans, and has been successfully cloned thereafter. That is, a gene of a human thrombomodulin precursor containing a signal peptide is cloned from a human lung cDNA library by a genetic engineering method, and then the entire gene sequence of thrombomodulin is analyzed to understand an amino acid sequence of 575 residues containing a signal peptide (usually, 18 amino acid residues are exemplified) (patent document 1). It is known that a mature thrombomodulin in which a signal peptide is cleaved is composed of 5 regions, i.e., an N-terminal region (positions 1 to 226; the positions in the case where the signal peptide is considered to be 18 amino acid residues, hereinafter the same), a region having 6 EGF-like structures (positions 227 to 462), an O-type oligosaccharide-attaching region (positions 463 to 498), a transmembrane region (positions 499 to 521), and an intracytoplasmic region (positions 522 to 557), from the N-terminal side of the mature peptide. As a portion having the same activity as that of the full-length thrombomodulin (i.e., the smallest active unit), a portion mainly formed of the 4 th, 5 th, 6 th EGF-like structures from the N-terminal side among the regions having 6 EGF-like structures is known (non-patent document 4).

In contrast to the fact that the full-length thrombomodulin is difficult to dissolve unless it is present in a surfactant, and a surfactant must be added as a preparation, it is known that there is a soluble thrombomodulin that can be smoothly dissolved even in the absence of a surfactant. It is only necessary to prepare soluble thrombomodulin so as not to contain at least a part or all of the transmembrane region, and it has been confirmed that, for example, soluble thrombomodulin formed only from 3 regions of the N-terminal region, the region having 6 EGF-like structures and the O-type sugar chain-added region (i.e., formed from the amino acid sequences at positions 19 to 516 of SEQ ID NO: 9) can be obtained by applying a recombinant technique, and that the recombinant soluble thrombomodulin has the activity of natural thrombomodulin (patent document 1). Some other examples of soluble thrombomodulin have been reported (patent documents 2to 9). In addition, as a natural type, soluble thrombomodulin derived from human urine and the like are exemplified (patent documents 10 and 11).

Incidentally, in the gene, as is often confirmed, a variety of variations are found in humans by natural variation or variation upon acquisition, and a sequence in which the amino acid at the 473 rd position of the human thrombomodulin precursor composed of the above-mentioned 575-residue amino acid sequence is Val and a sequence in which the amino acid at the 473 rd position is Ala have been confirmed. In the nucleotide sequence encoding this amino acid, the nucleotide sequence has a mutation at position 1418 into T and C, respectively (non-patent document 5). However, there was no difference in activity and physical properties at all, and it was considered that both were substantially the same.

It has been reported that thrombomodulin is effective in the treatment of disseminated (generalized) intravascular coagulation syndrome (hereinafter sometimes referred to as DIC) (non-patent document 6). In addition to the above, the use of thrombomodulin is expected to be used for the treatment and prevention of diseases such as Acute Coronary Syndrome (ACS), thrombosis, peripheral vascular occlusion, arteriosclerosis obliterans, vasculitis, functional disorders secondary to cardiac surgery, complications of organ transplantation, angina pectoris, transient ischemic attack, gestational toxicosis, diabetes, Liver VOD (Liver venous-occlusive disease; hepatic venous occlusion after acute hepatitis or bone marrow transplantation), Deep vein thrombosis (DVT; Deep venous thrombosis), and sepsis or Adult Respiratory Distress Syndrome (ARDS) (patent documents 12 to 14).

It is known that an International Normalized Ratio (hereinafter sometimes referred to as "INR") of a plasma sample of a sepsis patient is a value indicating blood coagulation disorder (Coagulopathy). For example, as an index of blood coagulation disorders reported in the International Emergency medical society (CCM) of 2003, aPPT >60 seconds and INR >1.5(Crit. Care Med., 2003; 31: 1250-. However, the INR value is not verified by clinical trials or the like, and has not been determined as a clear result. Actually, in phase 3 clinical trials with patients with severe sepsis, Tifacogin, a tissue factor pathway inhibitor as an anticoagulant, was reported to be more effective than those with INR >1.2 in the group of patients with INR >1.2 as a result of experiments with patients with INR >1.2 as a main subject (JAMA, July 9,2003, vol.290.no.2, P238-247). On the other hand, in the results of clinical trials relating to the treatment of sepsis using thrombomodulin, it has been reported that the effect is higher in patients having INR >1.5 in the patient data set of INR >1.2 than in patients having INR >1.2 (patent document 13).

In this way, when an anticoagulant therapy is performed for sepsis, it is difficult to say that the definition of coagulation disorders has been established that a high effect can be expected from some test results by targeting a patient accompanied with coagulation disorders, but a result opposite to the high effect is obtained. That is, the proposition of how to specify a target patient using an INR value to obtain a good result is not clear, and there is no technical common knowledge about what INR value a drug is particularly effective for a sepsis patient. Regarding the relationship between INR values and therapeutic effects, it is believed that the known part is at best an individual case for each agent.

Under such circumstances, the present inventors have also focused on thrombomodulin in anticoagulants and have conducted intensive studies on the therapeutic and/or ameliorating effects on sepsis. As a result, it has been found that, in the case where a sepsis patient is treated with a severe sepsis patient having 1 or more organ dysfunction (including a sepsis patient having only organ dysfunction of liver or kidney), among sepsis patients, unexpectedly, when INR is more than 1.4 among patients without organ dysfunction, the treatment and/or improvement of sepsis, that is, the treatment and/or improvement of sepsis with thrombomodulin, can be more effectively performed, and there is a special relationship, which cannot be expected by those skilled in the art, between a severe sepsis patient having 1 or more organ dysfunction among sepsis patients and INR > 1.4. Further, surprisingly, it has been found that a difference in mortality between thrombomodulin and placebo is more than 15% in patients with severe sepsis in which INR is a value of more than 1.4 and 1.6 or less, and is particularly significant (patent document 13). However, a method of administration for achieving a desired clinical effect has not been sufficiently elucidated.

Documents of the prior art

Patent document

Patent document 1: japanese laid-open patent publication No. Sho 64-6219

Patent document 2: japanese patent laid-open publication No. 5-213998

Patent document 3: japanese laid-open patent publication No. 2-255699

Patent document 4: japanese laid-open patent publication No. 3-133380

Patent document 5: japanese laid-open patent publication No. 3-259084

Patent document 6: japanese laid-open patent publication No. 4-210700

Patent document 7: international publication No. WO92/00325

Patent document 8: international publication No. WO92/03149

Patent document 9: international publication No. WO93/15755

Patent document 10: japanese laid-open patent publication No. 3-86900

Patent document 11: japanese laid-open patent publication No. 3-218399

Patent document 12: international publication No. WO2003/061687

Patent document 13: international publication No. WO2013/073545

Non-patent document

Non-patent document 1: american Colledge of check Physicians, CHEST/101/6/JUNE, 1992: 1481-1483

Non-patent document 2: suzuki hong zhi, medical competence あゆみ (medical progress) 1983; 125: 901

Non-patent document 3: good K et al, Blood 1990; 75: 1396-1399

Non-patent document 4: zushi M et al, J Biol Chem 1989; 246: 10351-10353

Non-patent document 5: wen DZ et al, Biochemistry 1987; 26: 4350-4357

Non-patent document 6: s.m.bates et al, br.j.of pharmacol, 2005; 144: 1017-1028

Non-patent document 7: crit. care med.2003; 31:1250-1256

Non-patent document 8: JAMA 2003; 290: 238-247

Non-patent document 9: a fruit (Ao ) について (Ao ) is JI at 3 rd phase bed test of ART-123 overseas における (Aojun 3 rd phase clinical trial result (Sungbo) of ART-123 overseas https:// www.asahi-kasei. co. jp/asahi/jp/news/2018/me180802.html (2018, 8 Yue 2 Ri, Xudihi Kaishi Co., Ltd.)

Disclosure of Invention

Problems to be solved by the invention

The present invention addresses the problem of providing a drug for effectively treating and/or improving sepsis associated with blood coagulation disorders, and a method for effectively treating and/or improving sepsis associated with blood coagulation disorders.

Means for solving the problems

The present inventors have intensively studied the therapeutic and/or ameliorating effect on sepsis by focusing on thrombomodulin in anticoagulants in order to solve the above problems. As a result, they have found that thrombomodulin is very effective in treating and/or ameliorating sepsis in a patient in whom it is confirmed that the patient is accompanied by blood coagulation disorder immediately before administration of thrombomodulin. The present inventors have further found that when thrombomodulin in an amount of 0.005 to 1mg/kg is intravenously administered to a blood coagulation disorder-associated sepsis patient at a frequency of 1 time per 1 day for at least 4 consecutive days, sepsis can be treated and/or ameliorated very effectively.

In addition, the present inventors have found that thrombomodulin is very effective in treating and/or improving sepsis in a patient who is confirmed to have a certain number of organ dysfunctions immediately before administration of thrombomodulin.

Specifically, the present invention includes the following embodiments.

[1] A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients whose value of the International Normalized Ratio (INR) immediately before administration is greater than 1.4.

[2]As described above [1]The medicament as described in (1), wherein the medicament is used for treating a platelet count of more than 30,000/mm immediately before administration³Is administered to the patient.

[3] The medicament as described in the above [1] or [2], wherein the medicament is for administration to the patient whose immediately before administration thrombin-antithrombin complex (TAT) value is 10ng/mL or more.

[4]As described above [1]～[3]The medicament of any one of above, wherein the medicament is for administration of a platelet count of greater than 30,000/mm immediately prior to administration³And patients with a Sofa score of 11 or less.

[5] A drug for use in the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose value of thrombin-antithrombin complex (TAT) immediately before administration is 10ng/mL or more.

[6] A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN FRAGMENT 1+ 2: F1+2) value immediately before administration is greater than 229 pmol/L.

[7] A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) immediately before the administration has a value of 250pmol/L or more.

[8] A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose protein C activity value immediately before the administration is 40% or less.

[9] A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

[10] A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose particle (MP) value immediately before administration is larger than 10 nm.

[11] A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients having an APACHE II score of less than 35 immediately before administration.

[12] A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient having organ dysfunction of 1 or more and 3 or less immediately before the administration.

[13] The medicament as described in [12], wherein the medicament is for administration to a patient other than a septic patient in which only either liver or kidney has organ dysfunction.

[14] The medicament as described in [1] or [2], wherein the medicament is for administration to the patient having organ dysfunction of 1 or more and 3 or less immediately before administration.

[15] The medicament as described in [14], wherein the medicament is for administration to a patient other than a septic patient in which only either liver or kidney has organ dysfunction.

[16] A drug for use in the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

[17] The drug as described in [1] or [2], wherein the drug is used for administration to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

[18] The drug as described in [1] or [2], wherein the drug is used for administration to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) value is more than 229pmol/L immediately before administration.

[19] The drug as described in [1] or [2], wherein the drug is used for administration to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) has a value of 250pmol/L or more immediately before administration.

[20] The medicament as described in [1] or [2], wherein the medicament is for administration to the patient whose protein C activity value immediately before administration is 40% or less.

[21] The medicament as described in [1] or [2], wherein the medicament is for administration to the patient whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

[22] The drug according to [1] or [2], wherein the drug is used for administration to the patient whose value of Microparticles (MP) immediately before administration is larger than 10 nm.

[23] The medicament as described in [1] or [2], wherein the medicament is for administration to the patient having an APACHE II score of less than 35 immediately prior to administration.

[24] The drug according to any one of the above [1] to [23], which is used for administration to a patient with severe sepsis having a dysfunction of cardiovascular system and/or a respiratory dysfunction.

[25] The medicament according to any one of the above [1] to [24], wherein the thrombomodulin is soluble thrombomodulin.

[26] The medicament according to any one of the above [1] to [25], wherein the thrombomodulin has the properties of the following (1) to (4),

(1) an effect of selectively binding to thrombin;

(2) promoting the activation of thrombin-based protein C;

(3) the effect of prolonging thrombin-based clotting time; and

(4) inhibiting the effects of thrombin-based platelet aggregation.

[27] The medicament according to any one of the above [1] to [26], wherein the thrombomodulin is a soluble thrombomodulin having the properties of the following (1) to (5),

(1) an effect of selectively binding to thrombin;

(2) promoting the activation of thrombin-based protein C;

(3) the effect of prolonging thrombin-based clotting time;

(4) inhibition of thrombin-based platelet aggregation; and

(5) has anti-inflammatory effect.

[28] The drug according to any one of the above [1] to [27], wherein the thrombomodulin is a peptide obtained from a transformed cell prepared by transfecting a host cell with a DNA encoding the amino acid sequence shown in SEQ ID NO.9 or SEQ ID NO. 11.

[29] The drug according to any one of the above [1] to [28], wherein the thrombomodulin is a peptide that comprises an amino acid sequence of any one of the following (i-1) or (i-2) and that has thrombomodulin activity,

(i-1) the amino acid sequence at positions 19 to 516 in the amino acid sequence set forth in any one of SEQ ID Nos. 9 and 11; or

(i-2) an amino acid sequence obtained by substituting, deleting or adding one or more amino acids in the amino acid sequence of (i-1).

[30] The pharmaceutical agent according to any one of the above [1] to [29], wherein the soluble thrombomodulin is:

(i) a peptide comprising the amino acid sequence at positions 367 to 480 in the amino acid sequence described in any one of SEQ ID NO.9 or SEQ ID NO. 11, and comprising the amino acid sequence described in any one of (ii-1) or (ii-2), wherein the peptide has thrombomodulin activity,

(ii-1) the amino acid sequence at position 19 to 244 of the amino acid sequence set forth in any one of SEQ ID NO.9 or SEQ ID NO. 11; or

(ii-2) an amino acid sequence obtained by substituting, deleting or adding one or more amino acids in the amino acid sequence of (ii-1) above.

[31] The drug according to the above [1] or [2], which is used for intravenous administration to a blood coagulation disorder-associated sepsis patient at a frequency of 1 time per 1 day for at least 4 consecutive days with 0.005 to 1mg/kg of the thrombomodulin.

[32] The medicament according to any one of the above [1] to [31], wherein immediately before administration is within 24 hours from the start of administration of thrombomodulin.

[33] A drug for use in the treatment and/or amelioration of sepsis, which comprises thrombomodulin as an active ingredient, and which is used for intravenous administration to a sepsis patient accompanied by blood coagulation disorders at a frequency of 1 time per 1 day at least for 4 consecutive days with 0.005 to 1mg/kg of thrombomodulin.

[34] A method of treating and/or ameliorating sepsis comprising the step of administering thrombomodulin to the patient whose value of the International Normalized Ratio (INR) immediately before administration is greater than 1.4.

[35]As described above [34]The method comprises administering a dose of a drug having a platelet count of greater than 30,000/mm immediately prior to administration³The step of administering thrombomodulin to the patient.

[36] The method as described in the above [34] or [35], which comprises the step of administering thrombomodulin to the patient whose immediately before administration thrombin-antithrombin complex (TAT) value is 10ng/mL or more.

[37]As described above [34]～[36]The method of any one of above, comprising administering to the subject a platelet count of greater than 30,000/mm immediately prior to administration³And administering thrombomodulin to the patient whose Sofa score is 11 or less.

[38] A method for treating and/or ameliorating sepsis, which comprises the step of administering thrombomodulin to a patient whose thrombin-antithrombin complex (TAT) value immediately before administration is 10ng/mL or more.

[39] A method of treating and/or ameliorating sepsis comprising the step of administering thrombomodulin to a patient whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN fracment 1+ 2: F1+2) value immediately prior to administration is greater than 229 pmol/L.

[40] A method for treating and/or ameliorating sepsis, comprising the step of administering thrombomodulin to a patient whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN FRAGMENT 1+ 2: F1+2) has a value of 250pmol/L or more immediately before administration.

[41] A method of treating and/or ameliorating sepsis comprising the step of administering thrombomodulin to the patient whose protein C activity value immediately before administration is 40% or less.

[42] A method for treating and/or ameliorating sepsis, which comprises the step of administering thrombomodulin to a patient whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

[43] A method for treating and/or ameliorating sepsis, comprising the step of administering thrombomodulin to a patient whose pre-administration Microparticle (MP) value is greater than 10 nm.

[44] A method of treating and/or ameliorating sepsis comprising the step of administering thrombomodulin to the patient having an APACHE II score of less than 35 immediately prior to administration.

[45] A method for treating and/or ameliorating sepsis, comprising the step of administering thrombomodulin to the patient having more than 1 and less than 3 organ dysfunctions immediately before the administration.

[46] The method of [45], comprising the step of administering to a patient other than a septic patient having organ dysfunction in only either the liver or kidney.

[47] The method as described in [34] or [35], which comprises the step of administering thrombomodulin to the patient having organ dysfunction of 1 or more and 3 or less immediately before the administration.

[48] The method of [47], comprising the step of administering to a patient other than a septic patient having organ dysfunction in only either the liver or kidney.

[49] A method for treating and/or ameliorating sepsis, which comprises the step of administering thrombomodulin to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

[50] The method as described in [34] or [35], which comprises the step of administering thrombomodulin to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

[51] The method as described in [34] or [35], which comprises the step of administering thrombomodulin to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) value is more than 229pmol/L immediately before the administration.

[52] The method as described in [34] or [35], which comprises the step of administering thrombomodulin to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) has a value of 250pmol/L or more immediately before administration.

[53] The method according to [34] or [35], which comprises the step of administering thrombomodulin to the patient whose protein C activity value immediately before administration is 40% or less.

[54] The method according to [34] or [35], which comprises the step of administering thrombomodulin to the patient whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

[55] The method according to [34] or [35], which comprises the step of administering thrombomodulin to the patient whose value of Microparticles (MP) immediately before administration is greater than 10 nm.

[56] The method of [34] or [35], comprising the step of administering thrombomodulin to the patient having an APACHE II score of less than 35 immediately prior to administration.

[57] The method according to [34] or [35], which comprises intravenously administering the thrombomodulin in an amount of 0.005 to 1mg/kg at a frequency of 1 time per day for at least 4 consecutive days to a patient suffering from blood coagulation disorder.

[58] The method according to any one of the above [34] to [57], wherein immediately before the administration, the time is within 24 hours from the start of the administration of the thrombomodulin.

[59] A method for treating and/or ameliorating sepsis, which comprises the step of intravenously administering thrombomodulin in an amount of 0.005 to 1mg/kg at a frequency of 1 time per day for at least 4 consecutive days to a sepsis patient accompanied by coagulation disorders.

[60] Use of thrombomodulin as a medicament for the treatment and/or amelioration of sepsis, wherein the medicament is for administration to a patient whose value of the International Normalized Ratio (INR) of plasma samples of the patient immediately before administration is greater than 1.4.

[61]As described above [60]]The use as described in (1), wherein the medicament is administered to a platelet count of more than 30,000/mm immediately before administration³The patient is administered the drug.

[62] The use as described in the above [60] or [61], wherein the medicament is a medicament for administration to a patient whose immediately before administration thrombin-antithrombin complex (TAT) value is 10ng/mL or more.

[63]As described above [60]]～[62]The use as described in any of the above, wherein the medicament is for administration to a subject having a platelet count of greater than 30,000/mm immediately prior to administration³And a drug administered to a patient having a Sofa score of 11 or less.

[64] The use as described in the above [60] or [61], wherein the medicament is a medicament for intravenous administration to a blood coagulation disorder-associated sepsis patient at a frequency of 1 time per 1 day by 0.005 to 1mg/kg of thrombomodulin for at least 4 consecutive days.

[65] The method according to any one of the above [60] to [64], wherein immediately before the administration, the time is within 24 hours from the start of administration of the thrombomodulin.

[66] Use of thrombomodulin as a drug for treating and/or improving sepsis, wherein the drug is a drug for intravenous administration to a sepsis patient accompanied by blood coagulation disorder at a frequency of 1 time per 1 day and 0.005 to 1mg/kg of thrombomodulin for at least 4 consecutive days.

[67] Use of thrombomodulin in the manufacture of a medicament for the treatment and/or amelioration of sepsis, wherein the medicament is a medicament for administration to a patient whose value of the International Normalized Ratio (INR) of plasma samples of the patient immediately before administration is greater than 1.4.

[68]As described above [67]]The use as described in (1), wherein the medicament is administered to a platelet count of more than 30,000/mm immediately before administration³The patient is administered the drug.

[69] The use as described in the above [67] or [68], wherein the medicament is a medicament for administration to a patient whose immediately before administration thrombin-antithrombin complex (TAT) value is 10ng/mL or more.

[70]As described above [67]]～[69]The use as described in any of the above, wherein the medicament is for administration to a subject having a platelet count of greater than 30,000/mm immediately prior to administration³And a drug administered to a patient having a Sofa score of 11 or less.

[71] The use as described in any of the above [67] or [68], wherein the medicament is a medicament for intravenous administration of thrombomodulin at a frequency of 0.005 to 1mg/kg for 1 time per 1 day for at least 4 consecutive days to a sepsis patient with blood coagulation disorder.

[72] The method according to any one of the above [67] to [71], wherein immediately before the administration, the time is within 24 hours from the start of administration of the thrombomodulin.

[73] Use of thrombomodulin for the manufacture of a medicament for the treatment and/or amelioration of sepsis, wherein the medicament is a medicament for intravenous administration of thrombomodulin in an amount of 0.005 to 1mg/kg to a sepsis patient accompanied by blood coagulation disorders at a frequency of 1 time per 1 day for at least 4 consecutive days.

[74] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administration to a patient whose thrombin-antithrombin complex (TAT) value immediately before administration is 10ng/mL or more.

[75] Use of thrombomodulin as a medicament for the treatment and/or amelioration of sepsis, wherein the medicament is a medicament for administration to a patient whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN fracment 1+ 2: F1+2) value immediately before administration is greater than 229 pmol/L.

[76] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administration to a patient whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN fracment 1+ 2: F1+2) value is 250pmol/L or more immediately before administration.

[77] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administration to a patient whose protein C activity value immediately before administration is 40% or less.

[78] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administration to a patient whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

[79] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administering to a patient whose particle (MP) value immediately before administration is greater than 10 nm.

[80] Use of thrombomodulin as a medicament for the treatment and/or amelioration of sepsis, wherein the medicament is a medicament for administration to a patient having an APACHE II score of less than 35 immediately prior to administration.

[81] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administration to a patient having organ dysfunction of 1 or more and 3 or less immediately before administration.

[82] The use as described in [81], wherein the medicament is a medicament for administration to a patient other than a septic patient in which only either liver or kidney has organ dysfunction.

[83] The use as described in the above [60] or [61], wherein the medicament is for administration to the patient having organ dysfunction of 1 or more and 3 or less immediately before administration.

[84] The use as described in [83], wherein the medicament is for administration to a patient other than a septic patient in which only either the liver or the kidney has organ dysfunction.

[85] Use of thrombomodulin as a medicament for treating and/or ameliorating sepsis, wherein the medicament is a medicament for administering to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

[86] The use as described in the above [60] or [61], wherein the medicament is a medicament for administration to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

[87] The use as described in the above [60] or [61], wherein the medicament is a medicament to be administered to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) value is more than 229pmol/L immediately before administration.

[88] The use as described in the above [60] or [61], wherein the medicament is a medicament to be administered to the patient whose PROTHROMBIN FRAGMENT 1+2(Prothrombin FRAGMENT 1+ 2: F1+2) immediately before administration has a value of 250pmol/L or more.

[89] The use as described in the above [60] or [61], wherein the medicament is a medicament for administration to the patient whose protein C activity value immediately before administration is 40% or less.

[90] The use as described in the above [60] or [61], wherein the medicament is a medicament to be administered to the patient whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

[91] The use as described in the above [60] or [61], wherein the drug is a drug to be administered to the patient whose value of Microparticles (MP) immediately before administration is larger than 10 nm.

[92] The use as described in the above [60] or [61], which is a medicament for administration to the patient having an APACHE II score of less than 35 immediately before administration.

[93] The use according to any one of the above [60] to [92], wherein immediately before the administration, the administration is traced back within 24 hours from the start of the administration of the thrombomodulin.

ADVANTAGEOUS EFFECTS OF INVENTION

According to the present invention, sepsis associated with blood coagulation disorders can be effectively treated and/or improved.

Drawings

Fig. 1 is a diagram showing a test protocol in example in which randomization is performed within 12 hours, primary administration is performed within 4 hours in principle from the time of randomization, and the number of platelets and INR values in plasma at the time immediately before administration (Baseline) and the like are re-measured at the time of primary administration, for 816 cases in which the total number of cases satisfying the blood coagulation disorder criterion and the organ dysfunction criterion in example 1 is confirmed within 24 hours. In the figure, R is a time at which randomization is completed.

Detailed Description

The present invention will be specifically described below with respect to some preferred embodiments (preferred embodiments for carrying out the present invention, hereinafter may be simply referred to as "embodiments" in the present specification), but the scope of the present invention is not limited to the specific embodiments described below.

Thrombomodulin in the present embodiment is known to have (1) an action of selectively binding to thrombin and (2) an action of promoting activation of thrombin-based protein C. It is also preferable that (3) the action of prolonging the thrombin-based coagulation time, (4) the action of inhibiting the thrombin-based platelet aggregation, and/or (5) the anti-inflammatory action are generally confirmed. The action of these thrombomodulins is sometimes referred to as thrombomodulin activity.

The thrombomodulin activity preferably has the effects of (1) and (2) above, and more preferably has the effects of (1) to (4) above. Further, it is preferable that all of the thrombomodulin activities have the actions (1) to (5).

The binding of thrombomodulin to thrombin can be achieved, for example, by the methods described in Thrombosi and Haemostasis 199370 (3): 418-422 or The Journal of Biological Chemistry 1989Vol.264, No.9pp.4872-4876 were confirmed by The test methods described in various publicly known documents. The activity of promoting the activation of protein C by thrombin can be easily confirmed by, for example, a test method which is described in various publicly known documents as typified by Japanese patent application laid-open No. Sho 64-6219, and the amount of activity or the presence or absence of the activity promoting the activation of protein C. In addition, the effect of prolonging the thrombin-based coagulation time and/or the effect of inhibiting platelet aggregation by thrombin can be similarly and easily confirmed. Further, regarding the anti-inflammatory effect, for example, the anti-inflammatory effect can be obtained by treating a blood 2008112: 3361-: 1267-.

The thrombomodulin in the present invention is not particularly limited as long as it has thrombomodulin activity, and is preferably soluble thrombomodulin that is soluble in water in the absence of a surfactant. As a preferred example of the solubility of the soluble thrombomodulin, 1mg/mL or more or 10mg/mL or more, preferably 15mg/mL or more or 17mg/mL or more, more preferably 20mg/mL or more, 25mg/mL or more or 30mg/mL or more, particularly preferably 60mg/mL or more, and in some cases 80mg/mL or more or 100mg/mL or more, respectively, with respect to water, for example, distilled water for injection (usually in the vicinity of neutrality in the absence of a surfactant such as Triton X-100 or polidocanol). When judging whether or not soluble thrombomodulin is dissolved, it is visually observed at a position of approximately 1000lux brightness immediately below a white light source after the dissolution, and a case where the insoluble substance is clear and does not contain a degree of clear confirmation at that time is regarded as a clear indicator. Further, the presence or absence of the residue may be checked by filtering.

As described above, as long as thrombomodulin has thrombomodulin activity, the molecular weight thereof is not limited, and the upper limit of the molecular weight is preferably 100,000 or less, more preferably 90,000 or less, further preferably 80,000 or less, particularly preferably 70,000 or less, and the lower limit thereof is preferably 50,000 or more, particularly preferably 60,000 or more. The molecular weight of the soluble thrombomodulin can be easily determined by a conventional method for determining the molecular weight of a protein, preferably by mass spectrometry, more preferably by MALDI-TOF-MS method. In order to obtain soluble thrombomodulin of a molecular weight in the target range, as described later, it is possible to prepare transformed cells by transfecting a DNA encoding soluble thrombomodulin into host cells using a vector, culture the transformed cells to obtain soluble thrombomodulin, and fractionate the soluble thrombomodulin using column chromatography or the like, thereby obtaining soluble thrombomodulin of a molecular weight in the above-mentioned target range.

The thrombomodulin in the present invention is preferably one that contains the amino acid sequences at the 19 th to 132 th positions of SEQ ID No. 1 known as the central part of thrombomodulin activity in human thrombomodulin, and is not particularly limited as long as it contains the amino acid sequences at the 19 th to 132 th positions of SEQ ID No. 1. The amino acid sequences at positions 19 to 132 in SEQ ID No. 1 may be naturally or artificially mutated, and one or more amino acids may be substituted, deleted, or added to the amino acid sequences at positions 19 to 132 in SEQ ID No. 1, as long as they have an action of promoting the activation of thrombin-based protein C, that is, thrombomodulin activity. The allowable degree of variation is not particularly limited as long as it has thrombomodulin activity, and for example, as the amino acid sequence, 50% or more homology, preferably 70% or more homology, more preferably 80% or more homology, further preferably 90% or more homology, particularly preferably 95% or more homology, and most preferably 98% or more homology may be shown. The amino acid sequences obtained by substituting, deleting, or adding one or more amino acids to such amino acid sequences are referred to as the same variant sequences. These variants can be easily obtained by using a general gene manipulation technique as described below. The thrombomodulin is not particularly limited as long as it has the above-mentioned sequence and at least has an action of selectively binding to thrombin as a whole to promote the activation of thrombin-based protein C, and preferably has an anti-inflammatory action together therewith.

The sequence of SEQ ID No. 3 is a sequence in which the 125 th amino acid Val of SEQ ID No. 1 is mutated to Ala, and preferably contains the 19 th to 132 th amino acid sequences of SEQ ID No. 3 as a thrombomodulin in the present invention.

As described above, thrombomodulin in the present invention is not particularly limited as long as it contains the 19 th to 132 th sequences of SEQ ID NO. 1 or SEQ ID NO. 3 or a peptide sequence containing at least the same variant sequence of the above sequences and having at least thrombomodulin activity, and preferable examples thereof include a peptide comprising the 19 th to 132 th sequences or the 17 th to 132 th sequences of SEQ ID NO. 1 or SEQ ID NO. 3 or a peptide comprising the same variant sequence of the above sequences and having at least thrombomodulin activity, and more preferable a peptide comprising the 19 th to 132 th sequences of SEQ ID NO. 1 or SEQ ID NO. 3. There are other forms of peptide which is more preferably formed from the same variant sequence at positions 19 to 132 or 17 to 132 in SEQ ID NO. 1 or SEQ ID NO. 3 and which has at least thrombomodulin activity.

In addition, as the thrombomodulin in another embodiment of the present invention, it is preferable that the thrombomodulin contains the amino acid sequences at the 19 th to 480 th positions of SEQ ID NO. 5, and the thrombomodulin is not particularly limited as long as the thrombomodulin contains the amino acid sequences at the 19 th to 480 th positions of SEQ ID NO. 5. The amino acid sequences at positions 19 to 480 of SEQ ID No. 5 may be the same variant sequences as long as they have the action of promoting the activation of thrombin-based protein C, that is, thrombomodulin activity.

The sequence of SEQ ID NO. 7 is a sequence in which the amino acid Val at the 473 rd position of SEQ ID NO. 5 is mutated to Ala, and preferably contains the amino acid sequences of 19 th to 480 th positions of SEQ ID NO. 7 as a thrombomodulin in the present invention.

As described above, the thrombomodulin in the present invention is not particularly limited as long as it contains the 19 th to 480 th sequences of SEQ ID NO. 5 or SEQ ID NO. 7 or a peptide sequence containing at least the same variant sequence of the above sequences and having at least thrombomodulin activity, and preferable examples thereof include a peptide comprising the 19 th to 480 th or 17 th to 480 th sequences of SEQ ID NO. 5 or SEQ ID NO. 7 or a peptide comprising the same variant sequence of the above sequences and having at least thrombomodulin activity, and more preferable examples thereof include a peptide comprising the 19 th to 480 th sequences of SEQ ID NO. 5 or SEQ ID NO. 7. There are also other embodiments of a peptide which is more preferably composed of the same variant sequence at positions 19 to 480 or 17 to 480 in SEQ ID NO. 5 or SEQ ID NO. 7 and has at least thrombomodulin activity.

In addition, as the thrombomodulin in another embodiment of the present invention, it is preferable to include the amino acid sequences at positions 19 to 515 of SEQ ID NO.9, and there is no particular limitation as long as it includes the amino acid sequences at positions 19 to 515 of SEQ ID NO. 9. The amino acid sequences at positions 19 to 515 in SEQ ID NO.9 may be the same variant sequences as long as they have an action of promoting the activation of thrombin-based protein C, that is, thrombomodulin activity.

The sequence of SEQ ID NO. 11 is a sequence in which the amino acid Val at position 473 of SEQ ID NO.9 is modified to Ala, and preferably contains the amino acid sequences of positions 19 to 515 of SEQ ID NO. 11 as a thrombomodulin in the present invention.

As described above, the thrombomodulin in the present invention is not particularly limited as long as it contains the 19 th to 515 th positions of SEQ ID NO.9 or SEQ ID NO. 11, or a peptide sequence containing at least the same variant sequence of the above-mentioned sequence and having at least thrombomodulin activity, and more preferable examples thereof include a peptide formed of the 19 th to 516 th positions, 19 th to 515 th positions, 17 th to 516 th positions or 17 th to 515 th positions of SEQ ID NO.9 or SEQ ID NO. 11, or a peptide formed of the same variant sequence of the above-mentioned sequence and having at least thrombomodulin activity, and particularly preferable examples thereof are a peptide formed of the 19 th to 516 th positions, 19 th to 515 th positions, 17 th to 516 th positions or 17 th to 515 th positions of SEQ ID NO. 9. Mixtures of these may also be mentioned as preferred examples. In addition, there are other embodiments in which a peptide consisting of the sequence at positions 19 to 516, 19 to 515, 17 to 516 or 17 to 515 in SEQ ID NO. 11 is particularly preferable. Mixtures thereof can also be cited as preferable examples. Further, a peptide which is formed from the same variant sequence as the above-mentioned sequence and has at least thrombomodulin activity is also exemplified as a preferable example. Thrombomodulin preferably has an anti-inflammatory effect at the same time.

As described above, the peptides having the same variant sequence also mean peptides in which one or more (i.e., one or more, and preferably several (e.g., 1 to 20, preferably 1 to 10, more preferably 1 to 5, and particularly preferably 1 to 3)) amino acids can be substituted, deleted, or added to the amino acid sequence of the subject peptide. The allowable degree of variation is not particularly limited as long as it has thrombomodulin activity, and for example, as the amino acid sequence, 50% or more homology, preferably 70% or more homology, more preferably 80% or more homology, further preferably 90% or more homology, particularly preferably 95% or more homology, and most preferably 98% or more homology may be shown.

Furthermore, as the thrombomodulin in the present invention, there may be mentioned, as preferred examples, a peptide of SEQ ID NO. 14(462 amino acid residues), a peptide of SEQ ID NO. 8(272 amino acid residues), or a peptide of SEQ ID NO. 6(236 amino acid residues) in Japanese patent laid-open No. 64-6219.

The thrombomodulin in the present invention is not particularly limited as long as it is a peptide having at least the amino acid sequences at the 19 th to 132 th positions of SEQ ID NO. 1 or SEQ ID NO. 3, and among them, a peptide having at least the amino acid sequences at the 19 th to 480 th positions of SEQ ID NO. 5 or SEQ ID NO. 7 is preferable, and a peptide having at least the amino acid sequences at the 19 th to 515 th positions of SEQ ID NO.9 or SEQ ID NO. 11 is more preferable. As the peptide having at least the amino acid sequence from position 19 to 515 of SEQ ID NO.9 or SEQ ID NO. 11, a peptide comprising the sequence from position 19 to 516, from position 19 to 515, from position 19 to 514, from position 17 to 516, from position 17 to 515 or from position 17 to 514 in the sequence of SEQ ID NO.9 or SEQ ID NO. 11 is more preferable. Further, a mixture of peptides composed of the 19 th to 516 th, 19 th to 515 th, 19 th to 514 th, 17 th to 516 th, 17 th to 515 th or 17 th to 514 th positions in the sequence of SEQ ID NO.9 or SEQ ID NO. 11 is more preferable to the mixture of the peptides of SEQ ID NO.9 or SEQ ID NO. 11.

In one embodiment, the thrombomodulin is not particularly limited as long as it is the above thrombomodulin, and a soluble thrombomodulin may be exemplified. As another mode, human thrombomodulin can be exemplified. As a further another mode, human soluble thrombomodulin may be exemplified. As a further another mode, α -thrombomodulin (gene recombination) can be exemplified. α -thrombomodulin (gene recombination) is an active ingredient of Recommulin (registered trademark) approved in the form of a pharmaceutical product in Japan. Alpha-thrombomodulin (gene recombination) is also sometimes referred to as ART-123.

In the case of the above mixture, the mixing ratio of the peptide from the 17 th position to the peptide from the 19 th position in each of SEQ ID Nos. 9 and 11 is (30: 70) to (50: 50), and preferable examples thereof include (35: 65) to (45: 55).

The mixing ratios of the peptides terminating at the 514 th, 515 th and 516 th positions in the sequences of SEQ ID NO.9 or 11 are (0: 0: 100) to (0: 90: 10), and in some cases (0: 70: 30) to (10: 90: 0) and (10: 0: 90) to (20: 10: 70).

The mixing ratio of these peptides can be determined by a conventional method.

The 19 th to 132 th sequences of SEQ ID No. 1 correspond to the 367 th to 480 th sequences of SEQ ID No.9, and the 19 th to 480 th sequences of SEQ ID No. 5 correspond to the 19 th to 480 th sequences of SEQ ID No. 9. The 19 th to 132 th bit sequences of SEQ ID No. 3 correspond to the 367 th to 480 th bit sequences of SEQ ID No. 11, and the 19 th to 480 th bit sequences of SEQ ID No. 7 correspond to the 19 th to 480 th bit sequences of SEQ ID No. 11. In addition, the sequences at positions 1 to 18 in the sequences of sequence numbers 1, 3,5, 7, 9 and 11 are all the same sequence.

As described below, these thrombomodulin of the present invention may be obtained from transformed cells prepared by transfecting DNA encoding these peptides (specifically, the base sequences of SEQ ID NO: 2, SEQ ID NO: 4, SEQ ID NO: 6, SEQ ID NO: 8, SEQ ID NO: 10, SEQ ID NO: 12, etc.) into host cells using a vector.

These peptides may have the above-mentioned amino acid sequence, and may have a sugar chain added thereto or not, and this is not particularly limited. In addition, in gene manipulation, the kind of sugar chain, the position of addition, or the degree of addition may be varied depending on the kind of host cell used. The binding position and type of sugar chain are known from Japanese patent application laid-open No. 11-341990, and the thrombomodulin of the present invention may be added with the same sugar chain at the same position. The ratio of two types of N-linked sugar chains, fucosyl-biantennary and fucosyl-triantennary, to which the thrombomodulin of the present embodiment is linked, can be exemplified by (100: 0) to (60: 40), preferably (95: 5) to (60: 40), and more preferably (90: 10) to (70: 30). The ratios of these sugar chains can be determined by a two-dimensional sugar chain map described in biochemistry experiments protocol 23 glycoprotein oligosaccharide interlocking assay (biochemistry experiments protocol 23 glycoprotein sugar chain assay), academic press center (1990) and the like. In the examination of the sugar composition of thrombomodulin in the present embodiment, neutral sugars, aminosugars, and sialic acids are detected, and the ratio thereof is1 to 30% by weight, preferably 2to 20% by weight, and more preferably 5 to 10% by weight, based on the protein content, respectively. These sugar contents can be determined by experiments in New chemical experiments in experimental experiments in th 3 saccharine-I-sugar タンパク (Up) (New chemical experiments in 3 saccharine-I glycoprotein (Up)), by the method described in Tokyo Chemicals (1990) (neutral sugar: phenol-sulfuric acid method, aminosugar: Elson-Morgan method, sialic acid: periodic acid-resorcinol method).

As described below, the thrombomodulin is obtained by genetic manipulation, but in the case of obtaining it by genetic manipulation, the nucleotide sequence of the amino acid sequence at positions 1 to 18 of coding sequence number 9, the nucleotide sequence of the amino acid sequence at positions 1 to 16 of coding sequence number 9, or other known signal sequences (for example, the signal sequence of human histiotype plasminogen activator) can be used as a signal sequence that can be used for expression (International publication No. 88/9811).

When a DNA sequence encoding thrombomodulin is introduced into a host cell, a method of introducing the DNA sequence encoding thrombomodulin by inserting it into a vector (particularly preferably an expression vector which can be expressed in animal cells) is preferable. The expression vector is a DNA molecule comprising a promoter sequence, a sequence which imparts a ribosome binding site to mRNA, a DNA sequence encoding a protein to be expressed, a splicing signal, a terminator sequence for terminating transcription, a replication initiation sequence, and the like, and examples of preferable animal cell expression vectors include Mulligan RC et al [ Proc Natl Acad Sci USA 1981, 78: 2072-2076, pSV2-X, Howley PM et al [ Methods in enzymology 1983,101: 387-402, Academic Press, pBP69T (69-6), etc. There are also other preferred ways of inserting into an expression vector capable of expression in a microorganism.

Examples of host cells that can be used for producing these peptides include animal cells. Examples of the animal cells include Chinese Hamster Ovary (CHO) cells, COS-1 cells, COS-7 cells, VERO (ATCC CCL-81) cells, BHK cells, dog kidney-derived MDCK cells, hamster AV-12-664 cells, and examples of the human cells include HeLa cells, WI38 cells, human 293 cells, and PER. C6 cells. CHO cells are most commonly, and are preferred, with dihydrofolate reductase (DHFR) deficient CHO cells being more preferred.

In addition, in the genetic manipulation process or the peptide preparation process, microorganisms such as Escherichia coli are also used in many cases, and it is preferable to use host-vector systems suitable for the respective microorganisms, and among the above host cells, suitable vector systems can be selected. The gene of thrombomodulin used in gene recombination technology has been cloned, and examples of production of thrombomodulin using gene recombination technology have been disclosed, and further purification methods for obtaining purified products thereof are known [ Japanese patent laid-open Nos. Sho 64-6219, Hei 2-255699, 5-213998, 5-310787, 7-155176, J Biol Chem 1989,264: 10351-10353]. Therefore, the thrombomodulin used in the present invention can be produced by using the methods described in the above reports or by the methods described in them. For example, Japanese patent laid-open publication No. Sho 64-6219 discloses Escherichia coli (Escherichia coli) K-12 strain DH5(ATCC deposit No. 67283) containing plasmid pSV2TMJ2 comprising DNA encoding full-length thrombomodulin. Furthermore, a strain of Life research (now, International patent organism depositary, national institute of advanced Industrial science and technology) Escherichia coli DH5/pSV2TM J2 (FERM BP-5570) can be used as the strain. The thrombomodulin of the present invention can be produced by a known gene manipulation technique using a DNA encoding the full-length thrombomodulin as a raw material.

In the present embodiment, thrombomodulin may be produced by a conventionally known method or according to a conventionally known method, and for example, the method of Shanben et al described above [ Japanese patent application laid-open No. Sho 64-6219 ] or Japanese patent application laid-open No. Hei 5-213998 can be referred to. That is, the human thrombomodulin gene may be prepared, for example, as a DNA encoding the amino acid sequence of SEQ ID No.9 by gene manipulation techniques, or may be further modified as necessary. For example, in order to prepare a DNA encoding the amino acid sequence of SEQ ID NO. 11 (specifically, a DNA comprising the nucleotide sequence of SEQ ID NO. 12), the codon encoding the 473 th amino acid of SEQ ID NO.9 (specifically, the 1418 th nucleotide of SEQ ID NO. 10) is modified according to Zoller MJ et al [ Methods in Enzymology 1983,100: 468-500, Academic Press ]. For example, a DNA obtained by converting base T at position 1418 of SEQ ID NO. 10 into base C can be prepared using a synthetic DNA for mutation having the base sequence shown in SEQ ID NO. 13.

The DNA thus prepared may be inserted into, for example, Chinese Hamster Ovary (CHO) cells to prepare transformed cells, the transformed cells may be appropriately selected, the cells may be cultured, and purified thrombomodulin may be produced from the obtained culture solution by a known method. The DNA encoding the amino acid sequence of SEQ ID No.9 (SEQ ID No. 10) is preferably transfected into the above-described host cells as described above.

The method for producing thrombomodulin in the present embodiment is not limited to the above-described method, and for example, it may be extracted and purified from urine, blood, other body fluids, etc., or may be extracted and purified from a tissue producing thrombomodulin, a culture solution of such a tissue, etc., or may be subjected to cleavage treatment with a protease, if necessary.

When the transformed cells are cultured, a medium used in ordinary cell culture can be used, and it is preferable to culture the transformed cells in advance in various media and select an optimal medium. For example, a medium may be used which comprises a known medium such as an MEM medium, a DMEM medium, or 199 medium as a minimal medium and further comprises an improved medium or supplements for various media. Examples of the culture method include a serum culture in which the culture is performed in a medium to which serum is added, and a serum-free culture in which the culture is performed in a medium to which serum is not added. The culture method is not particularly limited, and serum-free culture is preferable.

In the serum culture, when serum is added to the medium, bovine serum is preferable. Examples of the bovine serum include fetal bovine serum, newborn calf serum, and adult bovine serum, and any bovine serum suitable for cell culture can be used. In the serum-free culture, a commercially available medium can be used as the serum-free medium. Serum-free media suitable for various cells are commercially available, and for example, for CHO cells, there are CD-CHO, CHO-S-SFMII, CHO-III-PFM, which are sold by Invitrogen, IS CHO-CD media, which are sold by Irvine Scientific, and the like. These media may be used as they are, or they may be used with modifications or supplements. Further, as a serum-free medium, a DMEM medium containing insulin, transferrin and selenious acid added to 5 mg/L, respectively, can be exemplified. As described above, the medium is not particularly limited as long as it can produce thrombomodulin in the present embodiment. The culture method is not particularly limited, and any culture method such as batch culture, repeated batch culture, fed-batch culture, perfusion culture, and the like may be used.

When the thrombomodulin of the present invention is produced by the above cell culture method, it may be confirmed that the N-terminal amino acid has diversity by post-translational modification of the protein. For example, the amino acid at position 17, 18, 19 or 22 in SEQ ID NO.9 may form the N-terminus. In addition, for example, the N-terminal amino acid may be modified as in the case of converting glutamic acid at position 22 into pyroglutamic acid. Preferably, the amino acid at position 17 or 19 forms the N-terminus, and more preferably the amino acid at position 19 forms the N-terminus. In addition, another mode in which the 17 th amino acid is preferably N-terminal may be employed. The same examples as those of SEQ ID NO. 11 include the above modifications and variations.

In addition, when soluble thrombomodulin is produced using a DNA having the base sequence of SEQ ID NO. 10, the diversity of C-terminal amino acids may be observed, and a peptide having 1 amino acid residue in less may be produced. That is, the C-terminal amino acid may be modified as in the case where the amino acid at position 515 is C-terminal and the amino acid at position 515 is amidated. In addition, there are also cases where a peptide having 2 amino acid residues less is produced. That is, the amino acid at position 514 may form the C-terminus. Thus, it is possible to prepare a peptide having a high diversity of N-terminal amino acids and C-terminal amino acids, or a mixture thereof. Preferably, the amino acid at position 515 or the amino acid at position 516 forms the C-terminus, and more preferably, the amino acid at position 516 forms the C-terminus. In addition, another mode is also possible in which the C-terminal end is preferably formed by the amino acid at position 514. The same applies to the DNA having the base sequence of SEQ ID NO. 12, such as the above modifications and variations.

The thrombomodulin obtained by the above-described method may be a mixture of peptides in which diversity is observed at the N-terminus and the C-terminus. Specifically, there can be mentioned a mixture of peptides having the sequence at positions 19 to 516, 19 to 515, 19 to 514, 17 to 516, 17 to 515 or 17 to 514 in SEQ ID NO. 9.

Then, the method for isolating and purifying thrombomodulin from the culture supernatant or culture obtained as described above can be carried out according to the well-known techniques [ horiba tailing II, Genesis 30990 (basic experiments on proteins and enzymes), 1981 ]. For example, it is also preferable to use a chromatographic carrier having a functional group having an opposite charge to thrombomodulin immobilized thereon and ion exchange chromatography or adsorption chromatography utilizing an interaction between thrombomodulins. In addition, affinity chromatography utilizing specific affinity for thrombomodulin is also a preferred example. As a preferred example of the adsorbent, thrombin, which is a ligand of thrombomodulin, or an antibody against thrombomodulin is used. As such an antibody, an antibody of thrombomodulin having an appropriate property or recognizing an appropriate epitope can be used, and examples thereof include those described in Japanese patent publication No. 5-42920, Japanese patent application laid-open No. 64-45398, Japanese patent application laid-open No. 6-205692, and the like. Further, gel filtration chromatography or ultrafiltration using a molecular weight of thrombomodulin can be mentioned. Furthermore, there are also included a chromatography carrier having a hydrophobic group immobilized thereon and a hydrophobic chromatography using hydrophobic bonding with a hydrophobic site of thrombomodulin. Furthermore, hydroxyapatite can be used as a carrier for adsorption chromatography, and examples thereof include those described in Japanese patent application laid-open No. 9-110900. These methods may be appropriately combined. The degree of purification may be selected depending on the intended use, and is preferably such that a single band is obtained as a result of electrophoresis (preferably SDS-PAGE), or a single peak is formed as a result of gel filtration HPLC or reverse phase HPLC of the separated purified product. Of course, when two or more thrombomodulin are used, it is preferable to form a band substantially only of thrombomodulin, and it is not required to form a single band.

Specifically, the purification method of the present invention is exemplified by a method of purifying thrombomodulin using its activity as an index, and examples thereof include the following purification methods: subjecting the culture supernatant or the culture to a crude purification by Q-Sepharose Fast Flow on an ion exchange column to recover a fraction having thrombomodulin activity, followed by a main purification by means of an affinity column of DIP-thrombin-Sepharose (Dipropropylphosphothreonin agar) column to recover a fraction having strong thrombomodulin activity, concentrating the recovered fraction, and subjecting the concentrated fraction to a gel filtration to obtain a thrombomodulin active fraction in the form of a pure product [ good K et al, Blood 1990; 75: 1396-1399]. Examples of the thrombomodulin activity as an index include a promoting activity of thrombin-based activation of protein C. In addition, a preferred purification method is exemplified below.

Selecting proper ion exchange resin with good adsorption condition with thrombomodulin, and carrying out ion exchange chromatography purification. As a particularly preferred example, the method using Q-Sepharose Fast Flow equilibrated with 0.02mol/L Tris hydrochloride buffer (pH7.4) containing 0.18mol/L NaCl. After the appropriate washing, the crude thrombomodulin can be obtained by elution with, for example, 0.02mol/L tris hydrochloride buffer (pH7.4) containing 0.3mol/L NaCl.

Subsequently, for example, a substance having a specific affinity for thrombomodulin may be immobilized on a resin and subjected to affinity chromatography purification. Preferable examples include a DIP-thrombin-agarose column and an anti-thrombomodulin monoclonal antibody column. The DIP-thrombin-agarose column is equilibrated in advance with, for example, 20mmol/L Tris-hydrochloride buffer (pH7.4) containing 100mmol/L NaCl and 0.5mmol/L calcium chloride, and the crude purified product is packed, washed as appropriate, and eluted with, for example, 20mmol/L Tris-hydrochloride buffer (pH7.4) containing 1.0mol/L NaCl and 0.5mmol/L calcium chloride to obtain a purified thrombomodulin. In addition, in the antibody column for anti-thrombomodulin monoclonal, the following method can be exemplified: dissolving the monoclonal antibody of the anti-thrombomodulin in 0.1mol/L NaHCO containing 0.5mol/L NaCl₃The buffer solution (pH8.3) was brought into contact with CNBr-activated Sepharose 4FF (GE Healthcare Bio-Sciences Co.), and the column packed with the resin in which Sepharose 4FF and anti-thrombomodulin monoclonal antibody were coupled was equilibrated with, for example, 20mmol/L phosphate buffer solution (pH7.3) containing 0.3mol/L NaCl in advance, washed as appropriate, and then washed, for example, with 0.Elution was carried out using 100mmol/L glycine-HCl buffer (pH3.0) containing 3mol/L NaCl. The eluate is neutralized with an appropriate buffer, and can be obtained in the form of a purified product.

Subsequently, the obtained purified product was adjusted to pH3.5, and then filled in a cation exchanger (preferably SP-Sepharose FF (GE Healthcare Bio-Sciences) which is a strong cation exchanger) equilibrated with 100mmol/L glycine hydrochloride buffer (pH3.5) containing 0.3mol/L NaCl, and washed with the same buffer to obtain a non-adsorbed fraction. The obtained fraction is neutralized with an appropriate buffer solution to obtain a purified product of high purity. They are preferably concentrated by ultrafiltration.

Furthermore, a buffer exchange based on gel filtration is preferably carried out. For example, a high purity purified product concentrated by ultrafiltration is packed in a Sephacryl S-300 column or S-200 column equilibrated with 20mmol/L phosphate buffer solution (pH7.3) containing 50mmol/L NaCl, and is subjected to development fractionation with 20mmol/L phosphate buffer solution (pH7.3) containing 50mmol/L NaCl, whereby the thrombin-based promoting activity of protein C activation is confirmed, and the active fraction is recovered to obtain a buffer-exchanged high purity purified product. The thus obtained high-purity purified product is preferably filtered using an appropriate virus-removing membrane, for example, Planova 15N (asahi chemical industry co., ltd.) and then concentrated to a desired concentration by ultrafiltration, in order to improve safety. Preferably, the filtration is finally carried out using a sterile filtration membrane.

As one mode of the present invention, there is provided a drug for treatment and/or improvement of a sepsis patient, which comprises thrombomodulin as an effective ingredient, wherein the drug is for administration to a patient whose value of the International Normalized Ratio (INR) of a plasma sample of the patient immediately before the administration is larger than 1.4.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is used for a treatment in which the value of the International Normalized Ratio (INR) for a plasma sample of a patient immediately before administration is greater than 1.4 and the number of platelets in the sample of the patient immediately before administration is larger than 1.4Greater than 30,000/mm³Is administered to the patient.

In another aspect of the present invention, there is provided a drug for use in the treatment and/or amelioration of sepsis, which comprises thrombomodulin as an active ingredient, wherein the drug is for intravenous administration to a sepsis patient, wherein the drug is administered to the patient at a frequency of 1 time per 1 day and 0.005 to 1mg/kg of thrombomodulin for at least 4 consecutive days.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is administered to the patient who has a value of an International Normalized Ratio (INR) of a plasma sample of the patient immediately before the administration of the drug of more than 1.4 and a value of thrombin-antithrombin complex (TAT) in the sample of the patient immediately before the administration of the drug of 10ng/mL or more.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is for administration to a patient who is not a patient who does not appropriately control the infection site.

In addition, as another mode of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is used for a treatment in which the value of the International Normalized Ratio (INR) for a plasma sample of a patient immediately before administration is more than 1.4 and the number of platelets in the sample of the patient immediately before administration is more than 30,000/mm³And patients with a Sofa score of 11 or less.

In another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient whose thrombin-antithrombin complex (TAT) value in the sample is 10ng/mL or more in a patient immediately before the administration.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN fracmentt 1+ 2: F1+2) value is more than 229pmol/L in the sample of the patient immediately before the administration.

In another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN fracmentt 1+ 2: F1+2) value in the sample is 250pmol/L or more in the patient immediately before the administration.

In another aspect of the present invention, there is provided a drug for use in the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient whose protein C activity value in the sample is 40% or less of that of the patient immediately before the administration.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient whose antithrombin III (AT III) activity value in the sample of the patient immediately before the administration is less than 70%.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient whose value of Microparticles (MP) in the sample is larger than 10nm in a patient immediately before the administration.

In addition, according to another aspect of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, wherein the drug is for administration to a patient having an APACHE II score of less than 35 immediately before the administration.

In another aspect of the present invention, there is provided a drug for treating and/or ameliorating sepsis patients, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient having organ dysfunction of 1 or more and 3 or less immediately before administration.

In another aspect of the present invention, there is provided a drug for treating and/or ameliorating sepsis patients, which comprises thrombomodulin as an active ingredient, wherein the drug is to be administered to a patient having organ dysfunction of 1 or more and 3 or less immediately before administration, other than a sepsis patient having organ dysfunction only in either liver or kidney.

In addition, as another mode of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an effective ingredient, wherein the drug is for use in a treatment of a sepsis patient in which the value of the International Normalized Ratio (INR) immediately before administration is more than 1.4 and the number of platelets immediately before administration is more than 30,000/mm³And administration to a patient having 1 or more and 3 or less organ dysfunctions immediately before administration.

In addition, as another mode of the present invention, there is provided a drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an effective ingredient, wherein the drug is for use in a treatment of a sepsis patient in which the value of the International Normalized Ratio (INR) immediately before administration is more than 1.4 and the number of platelets immediately before administration is more than 30,000/mm³And administration is performed to a patient having 1 or more and 3 or less organ dysfunctions immediately before administration, except for a sepsis patient having organ dysfunctions only in either the liver or the kidney.

In the embodiment of the present invention, immediately before administration means within 24 hours, preferably within 12 hours, more preferably within 8 hours, further preferably within 4 hours, and particularly preferably within 2 hours from the start of administration of thrombomodulin, but when a plasma sample collected within 24 to 48 hours from the start of administration satisfies the above-mentioned conditions, high effectiveness may be achieved in some cases.

As one of preferable effects of treatment and/or improvement of sepsis, for example, "prevention of death of a patient due to sepsis" can be mentioned. In addition, the preferable effect is "prevention of deterioration of the general state of the patient due to sepsis".

In addition, as one of preferable effects of treatment and/or improvement of sepsis, for example, "reduction of mortality of sepsis patients" can be mentioned.

The increase in the blood concentration of the D-dimer as a blood coagulation marker suggests that fibrinolysis (2-fold fibrinolysis, fibrinolysis) is progressing and the like, and that there is a possibility that the formation of a fibrin thrombus, which is a characteristic of other symptoms associated with thromboembolism or hypercoagulable state, is expressed. When the drug of the present invention is administered to a patient, it is more preferable that a decrease in the blood D-dimer concentration or an increase in the blood D-dimer concentration be observed as compared with the case where no drug is administered.

Thrombin-antithrombin complex (TAT) as a marker of coagulation is thrombin and antithrombin as a representative inhibitor thereof is expressed as 1:1 in the ratio of 1. Generally, as coagulation is activated, a portion of thrombin rapidly binds to antithrombin, forming TAT. The concentration of TAT in normal blood is approximately lower than 3-4 ng/mL. By measuring the concentration of TAT in blood, the degree of blood coagulation activation at the time of blood collection can be known. When the drug of the present invention is administered to a patient, it is more preferable that a decrease in blood TAT concentration or an increase in inhibition thereof be observed as compared to the case where no drug is administered.

It is known that PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN FRAGMENT 1+ 2: F1+2) is also a coagulation activation marker like TAT, and it may be a peptide which is liberated from PROTHROMBIN upon conversion from PROTHROMBIN to thrombin. When the drug of the present invention is administered to a patient, it is preferable that a decrease in the blood prothrombin fragment 1+2 concentration or an increase in the blood prothrombin fragment 1+2 concentration be observed as compared with the case where the drug is not administered.

When the drug of the present invention is administered to a patient, it is more preferable that an increase in platelet count or a decrease in platelet count be observed as compared with the case where no drug is administered.

Antithrombin III (AT III) is one of physiological anticoagulant factors, and exhibits an anticoagulant effect by inhibiting the action of thrombin such as activated factor X or activated factor II (thrombin) by binding to the thrombin factor AT a ratio of 1: 1.

Microparticles (MP) are membrane vesicles formed from various cells such as platelets, monocytes and vascular endothelial cells, and are known to have the effects of promoting blood coagulation and inflammatory reaction.

Sepsis in the present embodiment is known to be a severe systemic infection as follows: diseases such as infection, malignant tumor, liver cirrhosis, renal failure, diabetes, and abnormal childbirth; or treatment for wounds or diseases such as indwelling catheters, transfusion instruments, dialysis, tracheotomy, etc., causes microorganisms to continuously or intermittently invade the blood from the focus of infection. When symptoms progress, septic shock is induced, that is, systemic shock is induced by rapid blood pressure decrease and peripheral circulation failure, and death is caused by disorders of important organs such as the lung, kidney, liver, heart, digestive tract, and central nervous system. In addition, as a complication accompanying sepsis, DIC is induced, or Adult Respiratory Distress Syndrome (ARDS) characterized by edema, hemorrhage or acute respiratory failure of the pulmonary interstitium is induced due to pulmonary capillary disorder accompanied by activation of neutrophils and accumulation of migration to the lung parenchyma, and the prognosis becomes very poor.

The sepsis in the present embodiment is Systemic Inflammatory Response Syndrome (SIRS) caused by infection. That is, in addition to the presence of infection, the SIRS-satisfying item ((1) body temperature) may be mentioned>38 ℃ or<36 ℃ and (2) heart rate>90/min, (3) respiratory rate>20/min or PaCO₂<32torr, (4) white blood cell count>12,000/. mu.L or<4000/. mu.L or immature leukocytes>10%) of the above 2, and sepsis can be basically diagnosed based on the disease state.

There are several methods as a diagnostic method of sepsis. These methods are summarized in Levy m.et al, crit.care.med.med., 31: 1250-. For example, there are methods of performing the diagnosis by a doctor, and methods of using a test value or the like. As an example of the latter, there is the following method: in 4 of 1) body temperature >38 ℃ or <36 ℃, 2) heart rate > 90/min, 3) respiratory rate > 20/min or need for artificial respiration, 4) white blood cell count >12,000/μ L or <4,000/μ L, or embryo cells > 10%, SIRS was diagnosed when 2 was met, and SIRS proved or suspected to be causative of a microorganism was diagnosed as sepsis [ LaRosa s, homepage of The Cleveland Clinic ]. Methods for approximating this are described in Members of the American College of Chest Physics/Society of clinical Care Medicine Consensus, Crit Care Med,20,864-874 (1992).

Examples of the state of sepsis (sepsis) include bacteremia, sepsis (septicema), Systemic Inflammatory Response Syndrome (SIRS), sepsis (SIRS which is proved to be or is suspected to be caused by microorganisms), severe sepsis, septic shock, refractory septic shock, or multiple organ dysfunction (hereinafter sometimes referred to as MODS) (harrison's original science 15 th edition 124, P828-833 Medical Sciences International). The above conditions may be exemplified by the symptoms effective as the therapeutic and/or ameliorating agent of the present invention.

The sepsis is not particularly limited as long as it satisfies the above diagnostic criteria, and sepsis particularly accompanied by blood coagulation disorder (septicemia) is an application target of the drug of the present invention. Examples of the index of blood coagulation disorder include INR, and in this case, the state of INR of a plasma sample of a patient is not particularly limited as long as it is greater than 1.2, preferably greater than 1.3, and more preferably greater than 1.4.

Alternatively, an abnormal decrease in platelet count (e.g., thrombocytopenia) may be used in place of INR or in addition to INR as an index of coagulation failure in sepsis associated with coagulation failure. As the lower limit of the reference value, 2 ten thousand/mm is exemplified³2.5 ten thousand/mm³3 ten thousand per mm³As an upper limit of the reference value, 20 ten thousand/mm can be exemplified³18 ten thousand per mm³15 ten thousand per mm³. A preferable range showing abnormal reduction in the number of platelets includes a range where the number of platelets is more than 3 ten thousand/mm³Less than 15 ten thousand/mm³The range of (1). Alternatively, the abnormal decrease in the number of platelets may be a decrease in the number of platelets exceeding 30% in 24 hours or less.

Alternatively, an abnormal increase in thrombin-antithrombin complex (TAT) value may be used in place of or in addition to INR as an index of coagulation failure in sepsis associated with coagulation failure. Examples of the lower limit of the reference value include 4ng/mL, 8ng/mL, 10ng/mL and 12 ng/mL. Examples of the upper limit include 2,000ng/mL, 5,000ng/mL and 10,000 ng/mL.

Alternatively, an abnormal increase in the prothrombin fragment 1+2(F1+2) value may be used in place of or in addition to INR as an index of coagulation disorders in sepsis associated with coagulation disorders. Examples of the lower limit of the reference value include 200pmol/L, 229pmol/L, 230pmol/L, and 250 pmol/L. Examples of the upper limit include 10,000pmol/L, 20,000pmol/L and 40,000 pmol/L.

Alternatively, an index of coagulation disorders in sepsis accompanied with coagulation disorders may be an abnormal decrease in protein C value instead of or in addition to INR. Examples of the upper limit of the reference value include 40%, 50%, and 60%. The lower limit is 5%, 8%, 10%.

Alternatively, an abnormal increase in the Microparticle (MP) value may be used instead of or in addition to INR as an index of coagulation failure in sepsis associated with coagulation failure. The lower limit of the reference value is 5nm, 8nm, or 10nm, for example. The upper limits are 350nm, 370nm and 400nm, for example.

Alternatively, an index of blood coagulation disorder in sepsis accompanied with blood coagulation disorder may be an abnormal decrease in antithrombin iii (at iii) value in place of INR or in addition to INR. Examples of the upper limit of the reference value include 45%, 60%, and 70%. The lower limit is 5%, 8%, 10%.

Alternatively, an abnormal increase in the D-dimer value may be cited as an index of coagulation failure in sepsis accompanied with coagulation failure instead of or in addition to INR. Examples of the lower limit of the reference value include 2,000ng/mL, 3,000ng/mL and 3,500 ng/mL. Examples of the upper limit include 50,000ng/mL, 60,000ng/mL and 70,000 ng/mL.

Regarding 1) the time (time 1) when diagnosis, judgment or confirmation of whether or not a sepsis patient is a sepsis patient with blood coagulation disorder is performed, and 2) the start time (time 2) of treatment and/or improvement of the patient using the drug of the present invention, the elapsed time from time 1 to time 2 is not particularly limited as long as the gist of the present invention is not departed, and the elapsed time from time 1 to time 2 may be 24 hours, for example.

As an example of bacteremia, a state in which the presence of bacteria in blood was confirmed can be illustrated, and the presence of the bacteria was confirmed by positive blood culture.

Examples of sepsis (septicema) include a state in which the presence of microorganisms or other toxins in blood is confirmed, and the presence of infection is excluded, so long as SIRS (body temperature of (1)) is observed>38 ℃ or<36 ℃ and (2) heart rate>90/min, (3) respiratory rate>20/min or PaCO₂<32torr, (4) white blood cell count>12,000/. mu.L or<4,000/. mu.L or immature leukocytes>10%) or more, and does not necessarily require blood culture positivity.

As a Systemic Inflammatory Response Syndrome (SIRS), a state in which DIC is ready as described above can be exemplified.

Examples of severe sepsis include sepsis accompanied by one or more of metabolic acidosis, organ hypoperfusion, acute encephalopathy, oliguria, hypoxemia, or organ dysfunction such as disseminated intravascular coagulation, or hypotension. In sepsis, a state in which organ dysfunction, organ hypoperfusion, or hypotension is present is called severe sepsis (severesepsilon). Organ hypoperfusion or perfusion abnormalities include lactic acidosis, oliguria, confusion, and the like. In severe sepsis, hypotension continues even when a sufficient infusion load is applied, and is called septic shock (septic shock).

The severe sepsis in the present embodiment is more specifically as follows.

Examples of septic shock include a condition in which a resuscitation with fluid replacement is unresponsive to hypotension (blood pressure of 90mmHg or less or 40mmHg lower than normal blood pressure) and organ failure is accompanied.

Examples of intractable septic shock include septic shock which lasts for 1 hour or more and is unresponsive to a fluid replacement or pressure raising agent.

As the Multiple Organ Dysfunction (MODS), a condition in which there is functional failure of 1 or more organs and medical intervention is required for maintaining stability can be exemplified.

The Sofa (Sequential organ failure assessment) score is an index obtained by quantifying the degree of damage of an important organ, and the degree of organ dysfunction is evaluated in 5 stages from 0 to 4 for 6 items of respiratory organs, coagulation system, liver function, cardiovascular system, central nervous system, and kidney function. When the score is more than 5, the mortality rate is considered to be about 20%. This score is useful in predicting the severity of sepsis. In addition to the Sofa score, Apache (acute physiology and chronic health assessment) II score is known as a score that can predict mortality or the like using 12 indexes such as respiration and circulation.

The infectious diseases causing sepsis are not particularly limited, and include pneumonia (acute pulmonary infection), urinary tract infection, intestinal tract infection, and bloodstream infection. The infectious diseases that cause sepsis to which the drug of the present invention is applied are preferably infectious diseases other than urinary tract infectious diseases (acute pulmonary infectious diseases, intestinal infectious diseases, bloodstream infectious diseases, and the like).

INR in the present embodiment is one of the examination indexes defining blood coagulation disorders. The INR is a prothrombin time (hereinafter, also referred to as PT) normalized by the difference between production lots of the thrombin-active enzyme preparation, and is defined as follows.

INR value ═ (clotting time in seconds for the sample to be measured/clotting time in seconds for the control sample)) (ISI value)

In the formula, the blood coagulation time (sec) of the sample to be measured represents PT of the plasma sample to be measured.

In addition, ISI represents an international sensitivity index.

As described above, the severe sepsis in the present embodiment can be exemplified by sepsis accompanied by one or two or more of metabolic acidosis, acute encephalopathy, oliguria, hypoxemia, disseminated intravascular coagulation and other organ dysfunction and hypotension symptoms. Severe refers to a serious condition at risk of life. Particularly, severe sepsis includes sepsis with 1 or more kinds of organ dysfunction. The organ dysfunction is not particularly limited, and may be any organ dysfunction that causes dysfunction due to sepsis, and organ dysfunction necessary for life maintenance is preferable. The 1 or more organ dysfunctions include 1 or more organ dysfunctions selected from the group consisting of circulatory organ disorders, respiratory organ disorders, renal dysfunction and liver dysfunctions, preferably 1 or more organ dysfunctions selected from the group consisting of respiratory organ disorders, circulatory organ disorders and renal dysfunctions, and more preferably 1 or more organ dysfunctions selected from the group consisting of respiratory organ disorders and circulatory organ dysfunctions. The number of organ dysfunctions is not particularly limited as long as it is1 or more, and two or more thereof may be preferred. Particularly, it is preferable to have both of respiratory organ disorders and circulatory organ disorders. Here, the respiratory disorder may be referred to as respiratory dysfunction, and the circulatory disorder may be referred to as cardiovascular dysfunction.

In addition, the number of organ dysfunctions of the patient in the present embodiment may be preferably 1 to 3. In addition, it is sometimes preferable to have at least either circulatory disorders or respiratory disorders as organ dysfunction.

The circulatory disorder is not particularly limited as long as it is a state generally known as circulatory disorder, and examples thereof include lowering of blood pressure and shock. Specifically, the use of a cyclic agonist is mentioned. In addition, as another example, a state in which the arterial blood lactic acid value >2mmol/L can be exemplified.

The respiratory disorder is not particularly limited as long as it is a state generally known as a respiratory disorder, and examples thereof include hypoxemia, acute lung injury, and dyspnea. Specifically, there may be mentioned a state where it is desired or necessary to use an artificial respiratory organ.

The renal dysfunction is not particularly limited as long as it is a state generally known as renal dysfunction, and examples thereof include renal dysfunction, oliguria, and renal failure. Specifically, creatinine ≧ 2.0mg/dL can be exemplified.

The liver function disorder is not particularly limited as long as it is a state generally known as liver function disorder, and examples thereof include liver function disorder, jaundice, and liver failure. Specifically, bilirubin is present in an amount of ≧ 2.0 mg/dL.

Such organ dysfunction is generally known as described in, for example, the publicly known publication "blood loss syndrome explaining 12392, therapeutic , which is a strategy for explaining and treating Sepsis" (journal of medicine, p38, by yotakuwa 2006), or "harvesting separation capsules for management of segment and segment shell 2008" (Crit Care med.2008 jan; 36 (327): 296-.

Since it is assumed that severe sepsis patients may be caused by factors other than sepsis, such as drug-induced organ dysfunction, it is preferable that the patients not include organ dysfunction including only the liver or the kidney. In addition, as a result of organ dysfunction, Thrombocytopenia (Thrombocytopenia) is known to occur. There is no particular limitation as long as the number of platelets in a patient to which the drug in the present embodiment is administered is less than 30 ten thousand/. mu.L, preferably less than 20 ten thousand/. mu.L, and preferably less than 15 ten thousand/. mu.L.

In addition, the patient in this embodiment preferably has an Apache (acute physiological and chronic health assessment) II score of less than 35. In addition, 25 or more may be exemplified.

The value of INR of the plasma sample of the sepsis patient in the present embodiment is not particularly limited as long as it is greater than 1.4, and in the case where INR is greater than 1.4, thrombomodulin is more effective for sepsis patients having 1 or more organ dysfunctions. The upper limit of INR is, for example, 2.0 or less, preferably 1.9 or less, more preferably 1.8 or less, further preferably 1.7 or less, and particularly preferably 1.6 or less. There may be a case where 1.5 or less is preferable. In addition, it may be preferable not to include INR of 1.7.

Note that "INR greater than 1.4" may be sometimes referred to as "INR > 1.4".

In this embodiment, DIC is a disease or syndrome as follows: a large amount of blood vessel coagulation-promoting substances are discharged due to tissue disorders in various diseases, the function of the coagulation system is extremely enhanced, and small thrombi (microthrombosis) are generated in blood vessels of the whole body to block the small blood vessels; at the same time, platelets or coagulation factors necessary for controlling bleeding are thereby consumed and become insufficient, resulting in abnormal hemostasis. In particular, due to the formation of intravascular fibrin, bleeding symptoms due to consumption coagulation fibrinolysis or organ failure symptoms due to microthrombus formation are found. DIC is also sometimes referred to as disseminated intravascular coagulation syndrome or generalized intravascular coagulation syndrome.

Clinical symptoms of DIC vary depending on the type of the underlying pathological condition, and it is preferable that a score of DIC be obtained from several test values as described below in addition to observation of bleeding symptoms and organ symptoms, and that DIC be diagnosed when the score is equal to or higher than a certain value. Examples of the test values include the number of platelets in blood, the concentration of plasmin-decomposed fibrin and fibrinogen decomposition products (hereinafter sometimes abbreviated as "FDP"), the concentration of D-dimer, the concentration of fibrinogen, and the prothrombin time. Furthermore, diagnosis of PreDIC (diagnosis of blood coagulation disorder) by lowering platelets, increasing the concentration of D-dimer or FDP, etc. without obtaining DIC score can be carried out by using に Seki する report on investigation using diagnosis standard of Disseminated Intravascular Coagulation (DIC)' study on specific blood coagulation disorder in great health province, report on study on specific disorders in 11 years, 1999: 65-72, Exhibit patent publication No. に Seki する on study on early diagnosis of DIC (study on early diagnosis of DIC in 11 years), study on specific disorders in great health province, report on study on blood coagulation disorder in 11 years, 1999: 73-77, Zhongke, Japanese patent, "study on diagnosis in DIC form- アンケート", study on clinical results of specific disorders in DIC (diagnosis) in China, 1999,40: 362-364).

In this embodiment, a septic patient whose INR value of a plasma sample of a patient is greater than 1.2, preferably greater than 1.3, and more preferably greater than 1.4 may be referred to as a patient with generalized DIC, and the drug for treating and/or improving sepsis in this embodiment may be used as a drug for treating and/or improving DIC whose INR value is greater than 1.4.

The drug in this embodiment may be used for DIC in some cases. Sepsis is also localized to SIRS caused by a critical clinical invasion of infectivity, and is closely related to DIC which is a disease causing infectious diseases. DIC is often complicated in sepsis, and the drug of the present embodiment may be used for patients with such DIC complicated sepsis. That is, the drug of the present embodiment may be used for a patient having or suspected of having either or both of DIC and sepsis.

The INR in the present embodiment can be measured, for example, as follows. That is, tissue thromboplastin and Ca were added to plasma (sample to be measured) obtained by adding sodium citrate²⁺The time (PT) until coagulation (fibrin deposition) was measured, and the time was determined in seconds, and evaluated in terms of the relative ratio (activity ratio) to the control sample. The activity ratio is determined by "clotting time (sec) of the sample to be tested/clotting time (sec) of the control sample", and the difference in test value is caused by the test execution mechanism depending on the sensitivity of the tissue thromboplastin used. The INR value is conceived to eliminate such a difference, and the standard result can be obtained by eliminating the facility-to-facility difference by evaluating the PT with the INR value corrected by an International sensitivity Index (hereinafter, abbreviated as ISI in some cases). ISI representation and internationalHow much the standard sample differs. ISI is determined by the respective tissue thromboplastin reagent, which is attached to the reagent. Examples of the thrombin reagent include, but are not limited to, Thromborel S (registered trademark: Sysmex), Thromboplastin C + (registered trademark: Sysmex). Human placenta Thromboplastin (ISI value close to 1.0) was used in thromboplastic S (registered trademark), and rabbit brain Thromboplastin (ISI value of about 1.8) was used in Thromboplastin C + (registered trademark).

ISI is added to the tissue thromboplastin reagent, and the INR value is calculated by the calculation formula of formula 1.

The control sample is not particularly limited as long as it is a commercially available normal mixed human plasma, and for example, commercially available normal mixed human sodium citrate plasma available from Kojin-Bio Co., Ltd., or International Bioscience Inc. can be used.

In the treatment of Sepsis, the following basic treatment is usually carried out based on known literature (provided separation clips include: International guidelines for management of segment segments and segment shapes: Crit Care med. 200836296-327, Crit Care med. 200332 (3)1250-56), but the use of thrombomodulin in combination with other agents is not limited to these agents.

In a patient with septic shock, in a case where hypotension continues even after the Central Venous Pressure (CVP) rises to a target value, dopamine may be administered in order to raise the mean blood pressure to at least 60 mmHg. Also, in the case of dopamine in excess of 20 μ g/kg/min, other vasoconstrictors (typically norepinephrine) may be added.

For the treatment of sepsis pathogenic bacteria, antibiotics are generally used. In selecting antibiotics, it is necessary to estimate based on the suspected cause, clinical condition, knowledge of microorganisms, knowledge of patterns of sensitivity common to specific hospital buildings, previous culture examination results, and the like.

The complete normalization of blood glucose values in septic patients improves the transition period for critically ill patients.

When an antibiotic substance is used, a sample such as blood, body fluid, or a wound can be examined, and a drug effective against pathogenic bacteria can be selected. For example, in septic shock or the like of unknown cause, gentamicin or tobramycin may be administered together with a third-generation cephalosporin. In addition, vancomycin was added when resistant staphylococci or enterococci were suspected.

The dosage is usually adjusted by continuous intravenous injection of insulin so as to keep the blood glucose level at 80-110 mg/dL (4.4-6.1 mmol/L).

Corticosteroid therapy has shown efficacy in the treatment of sepsis and is therefore sometimes administered in supplemental doses.

Recombinant activated protein C (rhAPC; doretrecogin-alpha) may be administered to patients at high risk of death (APACHE II score ≧ 25, multiple organ failure due to sepsis, septic shock, ARDS due to sepsis) without contraindication (bleeding, etc.).

Although the subject patient is limited, transfusion of concentrated red blood cells may be performed with a target of Hb 7.0 to 9.0 g/dL.

Erythropoietin (erythropoetin (epo)) is sometimes administered to sepsis patients when erythropoiesis is impaired due to renal failure.

In severe sepsis, DVT is sometimes administered prophylactically by administering low doses of heparin or low molecular weight heparin.

The medicament of the present invention may contain a carrier. As the carrier that can be used in the present invention, a water-soluble carrier is preferable, and an isotonic agent, a buffer, a thickener, a surfactant, a preservative, a painless agent, a pH adjuster, and the like that can be tolerated as an additive to a pharmaceutical product are generally preferable. For example, sucrose, glycerin, and other pH regulators containing inorganic salts may be added as additives. Further, amino acids, salts, sugars, surfactants, albumin, gelatin and the like may be added as required as disclosed in Japanese patent application laid-open Nos. 1-6219 and 6-321805. The method of adding these is not particularly limited, and the following methods may be mentioned: in the case of freeze-drying, for example, a method in which a solution containing at least one selected from an immunosuppressant and a therapeutic agent for hematopoietic malignancy and a solution containing thrombomodulin are mixed and then the mixed additive is added, as is generally performed; or a method comprising mixing an additive with at least 1 selected from an immunosuppressive agent and a therapeutic agent for hematopoietic malignant tumor dissolved in water, distilled water for injection or an appropriate buffer solution, adding and mixing a solution containing thrombomodulin, preparing a solution by the method, and freeze-drying the solution. When the drug of the present invention is a drug obtained by combining the respective drug components, the respective drugs are preferably produced by adding a carrier by an appropriate production method. The drug of the present invention may be provided in the form of an injection solution, or may be provided in the form of a lyophilized preparation dissolved for use.

In the formulation step, for example, 0.5 to 10mL of a solution containing 0.1 to 10mg of thrombomodulin, water for injection, and an additive is filled in an ampoule or a vial, and the mixture is prepared in the form of an aqueous solution preparation for injection. In addition, a method of preparing a lyophilized preparation by freezing and drying under reduced pressure can be exemplified.

The drug of the present invention is preferably administered by non-oral administration, for example, intravenous administration, intramuscular administration, subcutaneous administration, and the like. In addition, oral administration, rectal administration, intranasal administration, sublingual administration, etc. may be carried out. When the drug of the present invention is a drug in which the respective drug components are combined, the respective drug components are preferably administered by an appropriate administration method.

In the case of intravenous administration, a method of administering a desired amount at once (intravenous bolus) or intravenous administration by drip may be mentioned.

From the viewpoint of short administration time, a method of administering a desired amount at a time (intravenous bolus) is preferable. In particular, patients with sepsis are often urgent and administration in a short time is sometimes preferable. In the case of single administration, the time required for administration by syringe is usually of a certain extent, and the time required for administration varies depending on the amount of liquid to be administered, and may be 5 minutes or less, preferably 3 minutes or less, more preferably 2 minutes or less, further preferably 1 minute or less, and particularly preferably 30 seconds or less. The lower limit is not particularly limited, but is preferably 1 second or more, more preferably 5 seconds or more, and further preferably 10 seconds or more. The dose is not particularly limited as long as it is the above-mentioned preferred dose. In addition, intravenous drip administration is preferable in terms of ease of keeping the blood level of thrombomodulin constant.

The 1-day dose of the drug of the present invention varies depending on the age, body weight, degree of disease, administration route, etc. of a patient, and is usually preferably 20mg/kg or less, more preferably 10mg/kg or less, further preferably 5mg/kg or less, particularly preferably 2mg/kg or less, most preferably 1mg/kg or less, and is preferably 0.001mg/kg or more, more preferably 0.005mg/kg or more, further preferably 0.01mg/kg or more, particularly preferably 0.02mg/kg or more, most preferably 0.05mg/kg or more in terms of the amount of thrombomodulin.

In the case of intravenous bolus injection, the preferred dose is not particularly limited, but the upper limit of the dose for 1 day is preferably 1mg/kg or less, more preferably 0.5mg/kg or less, further preferably 0.1mg/kg or less, particularly preferably 0.08mg/kg or less, most preferably 0.06mg/kg or less, and the lower limit is preferably 0.005mg/kg or more, more preferably 0.01mg/kg or more, further preferably 0.02mg/kg or more, particularly preferably 0.04mg/kg or more.

In the case of administration to a patient weighing more than 100kg, the blood volume is not proportional to the body weight, and it may be preferable to administer the blood in a fixed amount of 6mg in view of a relative decrease in the blood volume with respect to the body weight.

In the case of intravenous administration by instillation, the preferred dose is not particularly limited, but the upper limit of the dose for 1 day is preferably 1mg/kg or less, more preferably 0.5mg/kg or less, further preferably 0.1mg/kg or less, particularly preferably 0.08mg/kg or less, most preferably 0.06mg/kg or less, and the lower limit thereof is preferably 0.005mg/kg or more, more preferably 0.01mg/kg or more, further preferably 0.02mg/kg or more, particularly preferably 0.04mg/kg or more.

Administered 1 time every 1 day or several times as needed. With respect to the administration interval, 1 time administration may be performed for 2 days to 14 days, preferably 1 time administration for 2 days to 7 days, and further preferably 1 time administration for 3 days to 5 days.

[ description of sequence Listing ]

Sequence number 1: amino acid sequence coded by gene for producing TME456

Sequence number 2: base sequence of amino acid sequence of coding sequence No. 1

Sequence number 3: amino acid sequence coded by gene for producing TME456M

Sequence number 4: base sequence of amino acid sequence of coding sequence No. 3

Sequence number 5: amino acid sequence encoded by gene for producing TMD12

Sequence number 6: base sequence of amino acid sequence of coding sequence No. 5

Sequence number 7: amino acid sequence encoded by gene for producing TMD12M

Sequence number 8: base sequence of amino acid sequence of coding sequence No. 7

Sequence number 9: amino acid sequence encoded by gene for producing TMD123

Sequence number 10: base sequence of amino acid sequence of coding sequence No.9

Sequence number 11: amino acid sequence encoded by gene for producing TMD123M

Sequence number 12: base sequence of amino acid sequence of coding sequence No. 11

Sequence number 13: synthetic DNA for mutagenesis used for site-directed mutagenesis

Examples

The present invention will be specifically described below with reference to examples and test examples, but the present invention is not limited to these examples at all.

The thrombomodulin of the present invention used in the test examples was prepared according to the method of the above-mentioned Shanben et al (the method described in Japanese patent application laid-open No. Sho 64-6219). An example of the production thereof is shown below. The thrombomodulin obtained in the present production example was confirmed for safety by a single and repeated intravenous administration test using rats and monkeys, a mouse reproduction test, a local irritation test, a safety pharmacological test, a virus inactivation test, and the like.

Production example 1

< obtaining of thrombomodulin >

The thrombomodulin was obtained by transfecting DNA encoding the amino acid sequence of SEQ ID NO.9 (specifically, DNA consisting of the base sequence of SEQ ID NO. 10) into Chinese Hamster Ovary (CHO) cells and obtaining a high-purity purified product from the culture broth of the transformed cells by the purification method of the conventional method, the active fraction of which was recovered in 20mmol/L phosphate buffer (pH7.3) containing 50mmol/L NaCl. Further, the solution was concentrated by ultrafiltration to obtain 11.0mg/mL of a thrombomodulin (in this specification, it may be abbreviated as TMD 123).

< Polysorbate solution preparation >

0.39g of polysorbate 80 was weighed into a glass beaker, and 30mL of water for injection was added for dissolution.

< preparation and filling of drug solution >

Into a 5L stainless steel container, 2239mL of the above-obtained TMD123 solution (equivalent to 24.63g based on the amount of soluble thrombomodulin protein, to which 5% was added in excess) was added. The polysorbate solution obtained above was further added, and 27.9g of sodium chloride was added. 600mL of water for injection was added and stirred. A1 mol/L hydrochloric acid solution was added to adjust the pH to 6.0. Further, 3940g of water for injection was added in total, and the mixture was uniformly mixed and stirred. The resulting liquid medicine was filtered and sterilized by a filter (MCGL 10S made by Millipore) having a pore size of 0.22 μm. The filtrates were filled in ampoules with 1.1g each to give a TMD123 preparation.

Production example 2

A DNA encoding the amino acid sequence of SEQ ID NO. 11 (specifically, a DNA consisting of the base sequence of SEQ ID NO. 12) was transfected into Chinese Hamster Ovary (CHO) cells, and a purified thrombomodulin (herein, sometimes abbreviated as TMD123M) solution was obtained from the culture broth of the transformed cells by the purification method of the above-mentioned conventional method, and a TMD123M preparation was obtained by the same method as described above.

Production example 3

DNA encoding the amino acid sequence of SEQ ID NO. 1 (specifically, DNA consisting of the base sequence of SEQ ID NO. 2) was transfected into Chinese Hamster Ovary (CHO) cells, purified thrombomodulin (herein, sometimes abbreviated as TME456) was obtained from the culture broth of the transformed cells by the purification method of the conventional method described above, and a TME456 preparation was obtained by the same method as described above.

Production example 4

DNA encoding the amino acid sequence of SEQ ID NO. 3 (specifically, DNA consisting of the base sequence of SEQ ID NO. 4) was transfected into Chinese Hamster Ovary (CHO) cells, purified thrombomodulin (hereinafter, sometimes abbreviated as TME456M) was obtained from the culture broth of the transformed cells by the purification method of the above-mentioned conventional method, and a TME456M preparation was obtained by the same method as described above.

Production example 5

DNA encoding the amino acid sequence of SEQ ID NO. 5 (specifically, DNA consisting of the base sequence of SEQ ID NO. 6) was transfected into Chinese Hamster Ovary (CHO) cells, purified thrombomodulin (herein, occasionally referred to simply as TMD12) was obtained from the culture broth of the transformed cells by the purification method of the above-mentioned conventional method, and a TMD12 preparation was obtained by the same method as described above.

Production example 6

DNA encoding the amino acid sequence of SEQ ID NO. 7 (specifically, DNA consisting of the base sequence of SEQ ID NO. 8) was transfected into Chinese Hamster Ovary (CHO) cells, purified thrombomodulin (hereinafter, sometimes abbreviated as TMD12M) was obtained from the culture broth of the transformed cells by the purification method of the above-mentioned conventional method, and a TMD12M preparation was obtained by the same method as described above.

Production example 7 preparation of placebo preparation

< Polysorbate solution preparation >

0.4g of polysorbate 80 was measured in a glass beaker, and dissolved by adding 30mL of water for injection.

< preparation and filling of drug solution >

2000mL of water for injection was added to a 5L stainless steel container. And the polysorbate solution obtained above was added. Further, water for injection was added to make the total amount 4000g, and the mixture was uniformly mixed and stirred. The resulting liquid medicine was filtered and sterilized by a filter (MCGL 10S, Millipore) having a pore size of 0.22 μm. The filtrates were filled into ampoules at 1.1g, respectively, to give placebo preparations.

[ example 1]

< test method >

TMD-123 produced according to production example 1 was used as thrombomodulin, and a random double-blind Placebo (Placebo) test was performed on subjects of severe sepsis associated with blood coagulation disorders. The total number of subjects was 816, 402 of which were assigned to the TMD-123 administration group and 414 were assigned to the placebo administration group. Among them, 800 patients administered with test drugs (395 in the TMD-123 administration group and 405 in the placebo administration group) were subjected to the test. TMD-123 was given 1 daily 1 bolus up to 6 days in an amount of 0.06 mg/kg. The formulation prepared according to production example 7 was used as a placebo. In order to suppress the occurrence of side effects due to overdosing, 1 intravenous bolus injection of 1 day and 1 continuous 6 days was uniformly administered at a fixed dose of 6mg to a patient weighing more than 100 kg.

In this test, the following coagulation disorders are indicated: 1) INR>1.4 and represents 2) a platelet count of more than 3 ten thousand/mm³Less than 15 ten thousand/mm³Or a decrease in platelet count of greater than 30% within 24 hours.

The INR value in plasma of the patient before administration of the test drug was measured by the method described in formula 1 above. The platelet count of the patient is determined by methods customary per se.

In this test, the subject patient is a patient having sepsis-related organ dysfunction a and/or organ dysfunction b.

1) Organ dysfunction a cardiovascular dysfunction requiring both sufficient infusion load and pressure-raising agent to maintain mean arterial pressure of 65mmHg or more

2) Organ dysfunction b has an urgent necessity for artificial respiration, PaO₂/FiO₂Respiratory dysfunction with a ratio of less than 250 (wherein, in the case where the lung is the site of infection, less than 200)

The aforementioned dysfunction of the cardiovascular system is sometimes referred to as circulatory organ dysfunction. In addition, the respiratory dysfunction is sometimes referred to as respiratory organ dysfunction.

In this test, in 816 cases in which the total number of cases confirmed to satisfy the above-mentioned blood coagulation disorder criteria and the above-mentioned organ dysfunction criteria was within 24 hours, randomization was performed within 12 hours, and the initial administration was performed within 4 hours in principle from the time of randomization. At the time of this initial administration, the platelet count at the time immediately before administration (Baseline) and INR value in plasma were re-measured (fig. 1).

The above "confirmation that the blood coagulation disorder criterion and the organ dysfunction criterion are satisfied within 24 hours" means that the time from the first satisfaction of any of the INR value, the platelet count, and the organ dysfunction to the time when all of the remaining criteria are satisfied is within 24 hours. The phrase "randomization is performed within 12 hours" means that the time from the confirmation of the blood coagulation disorder criterion and the organ dysfunction criterion to the completion of the acceptance confirmation, the test registration, and the randomization completion of the patients who participated in the test at the Clinical test coordination Center (CCC) and the Informed Consent (IC) of the patients is obtained within 12 hours (fig. 1).

The transition period from the start of administration to day 28 was confirmed, and the Mortality (Mortality) of each patient group was calculated as a main efficacy evaluation item. In addition, the mortality Difference between TMD-123 and placebo was calculated as Difference (Difference).

In addition, as a main safety evaluation item, Severe Adverse Events (SAE), severe Bleeding Events (MBE) and Anti-Drug antibodies (Anti-Drug-Antibody; ADA) were observed.

< test results >

The above 800 examples were used as a Full Analysis Set (FAS), and the validity of the Full analysis set and the validity of the partial data set from various viewpoints were analyzed (Table 1).

[ tables 1-1]

[ tables 1-2]

[ tables 1 to 3]

In the above table, "BL INR > 1.4" refers to the data set in the full analysis set formed by patients with INR greater than 1.4 at the time immediately before dosing (Baseline).

In the above table, "BL INR ≦ 1.4" refers to a data set formed by patients whose INR at the time immediately before administration (Baseline) was 1.4 or less in the entire analysis set.

In the above table, "BL INR>1.4 and PLT>30,000(mm³) "means that INR at the time immediately before administration (Baseline) is greater than 1.4 and platelet count at the time immediately before administration (Baseline) is greater than 30,000 (mm) in the total analysis set³) The patient formed a data set.

In the above tables, "BL INR ≦ 1.4 and/or PLT ≦ 30,000 (mm)³) "means that the INR at the time immediately before administration (Baseline) in the entire analysis set is 1.4 or less and/or that immediately before administration (Baseline)The platelet count at time was 30,000 (mm)³) The following patient formed data sets.

In the above tables, "TAT ≧ 10 (ng/mL)" means a data set composed of patients whose thrombin-antithrombin complex (TAT) is 10ng/mL or more in the entire analysis set.

Incidentally, the "TAT" in the above tables is, of course, a value measured for a thrombin-antithrombin complex (TAT) at a time immediately before administration (Baseline).

In the above table, "BL F1+2 ≧ 250 (pmol/L)" means a data set in the entire analysis set, which is formed by patients whose PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN frament 1+ 2: F1+2) immediately before administration (Baseline) is 250pmol/L or more.

In the above table, "BL F1+2>229 (pmol/L)" refers to the data set in the full analysis set formed by patients with PROTHROMBIN FRAGMENT 1+2(PROTHROMBIN FRAGMENT 1+ 2: F1+2) greater than 229pmol/L immediately prior to dosing (Baseline).

"BL AT III < 70%" refers to the data set in the full analysis set formed by less than 70% of patients with antithrombin III (AT III) immediately prior to dosing (Baseline).

In the above table, "BL MP >10 (nm)" refers to a data set in the full assay set formed by patients with microparticles (microparticles) larger than 10nm immediately before administration (Baseline).

In the table, the phrase "BL protein C ≦ 40%" refers to a data set of patients in the entire analysis set whose protein C at the time immediately before administration (Baseline) is 40% or less.

In the above table, "BL protein C > 40%" refers to a data set formed by more than 40% of patients at the time of immediately before administration (Baseline) in the total analysis set.

In the table, the "BL APACHE II score ≧ 25" refers to a data set composed of patients whose APACHE II score at the time immediately before administration (Baseline) is 25 or more in the entire analysis set.

In the above table, "BL APACHE II score < 25" refers to the data set in the full analysis set formed by patients with APACHE II scores less than 25 at the time immediately prior to dosing (Baseline).

In the table, the "BL APACHE II score ≧ 35" refers to a data set composed of patients whose APACHE II score at the time immediately before administration (Baseline) is 35 or more in the entire analysis set.

In the above table, "BL APACHE II score < 35" refers to the data set in the full analysis set formed by patients with APACHE II scores less than 35 at the time immediately prior to dosing (Baseline).

In the above table, "the number of BL organ dysfunctions" means the number of organ dysfunctions that the patient of the full analysis set had at the time immediately before administration (Baseline).

In the table, the phrase "1 ≦ BL number of organ dysfunctions ≦ 3" refers to a data set formed from patients having 1 to 3 numbers of organ dysfunctions at the time immediately before administration (Baseline) in the entire analysis set.

In the above table, "BL INR>1.4 and PLT>30,000(mm³) And 1 ≦ number of BL organ dysfunctions ≦ 3 "means that INR from the time immediately before administration (Baseline) is greater than 1.4 and platelet count at the time immediately before administration (Baseline) is greater than 30,000 (mm) in the full assay set³) And a data set formed by patients with 1-3 organ dysfunction at the time immediately before administration (Baseline).

In the above table, "BL arterial lactate ≦ 6 (mmol/L)" means a data set formed from patients whose arterial lactate immediately before administration (Baseline) was 6mmol/L or less in the entire analysis set.

In the above table, "BL arterial blood lactate >6 (mmol/L)" refers to the data set in the full analysis set formed by patients with arterial blood lactate greater than 6mmol/L just prior to dosing (Baseline).

In the above table, "BL serum creatinine <2 (mg/dL)" refers to the data set in the full assay set formed by patients with serum creatinine less than 2mg/dL immediately prior to dosing (Baseline).

In the above table, "BL serum creatinine ≧ 2 (mg/dL)" means a data set formed by patients whose serum creatinine was 2mg/dL or more immediately before administration (Baseline) in the entire analysis set.

In the above table, "diabetes-afflicted patient" refers to a data set composed of patients who complicated with diabetes immediately before administration (Baseline) in the entire analysis set.

In the above table, "diabetes non-sufferers" means a data set formed from patients who did not develop diabetes immediately before administration (Baseline) in the entire analysis set.

In the above table, "heparin user" refers to the data set in the full analysis set formed by patients who used low doses of heparin immediately prior to dosing (Baseline).

In the above table, "heparin non-user" refers to the data set in the full analysis set formed by patients not using low doses of heparin immediately prior to dosing (Baseline).

In the above table, "4 or more administrations" means a data set formed by patients who were administered the test drug (TMD-123 or placebo) 4 times or more (i.e., 4 to 6 times) in the total analysis set.

In the above table, "4 or more administrations" mean, of course, "administration for at least 4 consecutive days".

In the above table, "BL INR >1.4 and 4 or more administrations" refers to a data set formed from patients who had INR greater than 1.4 at the time immediately before (Baseline) administration and who had been administered the test drug (TMD-123 or placebo) 4 or more times (i.e., 4 to 6 times) in the total analysis set.

In the above table, "BL INR>1.4, 4 or more administrations and PLT>30,000(mm³) "means that INR at the time immediately before administration (Baseline) in the total analysis set is more than 1.4, administration of the test drug (TMD-123 or placebo) is performed 4 times or more (i.e., 4 to 6 times), and the number of platelets at the time immediately before administration (Baseline) is more than 30,000 (mm)³) The patient formed a data set.

In the above table, "BL D-dimer ≧ 3,500 (ng/mL)" means a data set formed by patients whose D-dimer immediately before administration (Baseline) was 3,500ng/mL or more in the entire analysis set.

The above-mentioned "BL INR>1.4 and PLT>30,000(mm³) In case 634, the elapsed time from the time immediately before administration (Baseline) to the time of initial administration (leftmost column in table 2), the effectiveness exhibited by the patient group to which the test drug was administered within the elapsed time (rightmost column in table 2), and the like are summarized in the table (table 2).

[ Table 2]

In the total analysis set (800 cases), the influence of the history from the time when the blood coagulation disorder criterion within 24 hours and the above-mentioned organ dysfunction criterion were confirmed (at the time of initial measurement) to the time immediately before administration (Baseline) (at the time of re-measurement) on the INR value in plasma of patients was summarized in the following table (table 3).

[ Table 3]

In the total analysis set (800 cases), the influence of the history from the time when the blood coagulation disorder criterion within 24 hours and the above-mentioned organ dysfunction criterion were confirmed (at the time of initial measurement) to the time immediately before administration (Baseline) (at the time of re-measurement) on the platelet count of the patient is summarized in the following table (table 4).

[ Table 4]

Regarding the number of platelets, no significant change was observed in the blood coagulation disorder within 24 hours from the time of the measurement. Further, it was found that, in patients showing INR >1.4, INR >1.4 was maintained (maintenance of blood coagulation disorders) in 70% or more of the patients within 24 hours from the measurement.

As described above, the number of platelets in the patient is confirmedAnd the measured value of INR value in plasma satisfies the above condition (INR)>1.4 and platelet count>30,000(mm³) In the above two tables, it is revealed that the coagulation disorder is substantially maintained within 24 hours, as one reason why the administration is started within 24 hours at the latest, and thus it is considered preferable.

In addition, 800 patients were treated with the test drug and the "BL INR" mentioned above>1.4 and PLT>30,000(mm³) In the case of "(634 cases), there was no significant difference in the incidence of severe major bleeding events, and no significant difference was observed from the placebo group.

Note that the Sofa score defined in the present invention is not a normal calculation method of the Sofa score, and is a score calculated by evaluation of 5 organs (respiratory organ, circulatory organ, liver, kidney, blood coagulation) except for evaluation by Glasgow Coma score method (Glasgow Coma Scale), and the score range is 0 to 20. Further, the Sofa score of the respiratory organ and the circulatory organ was evaluated using a provisional value according to the following criteria.

Respiratory organs: in patients with a deficiency in the P/F ratio, the score was 3 when artificial respiration management was present and 0 when no artificial respiration management was present.

Circulatory organs: patients who met the criteria for selection of circulating organs set in clinical trials were assigned a <1> score and patients who were given "Dobutamine (Dobutamine)" or "Dopamine not assigned >5 ug/kg/min" (Dopamine) were assigned a <2> score. The score of <3> is1 for patients who do not meet <1> or <2> but have an average blood pressure of less than 70mmHg at the time of eligibility confirmation, and the score of 0 for patients who do not meet <1> or <3 >.

The APACHE (acute physiological and chronic health assessment) II score defined in the present invention is a scoring system for evaluating the severity of a disease state in a patient who enters a centralized treatment room, and is obtained as the sum of scores given by evaluating 12 physiological indexes, ages, and complicated chronic diseases. The higher the score is, the higher the severity is determined to be, and the range of the score is 0 to 71.

Industrial applicability

The thrombomodulin-containing drug of the present invention is useful as a drug capable of effectively treating and/or ameliorating sepsis associated with blood coagulation disorders.

Sequence listing

<110> Asahi Kasei Pharma corporation

<120> drug for treating and/or improving sepsis associated with blood coagulation disorders

<130> 181522WO01

<150> US 62/748,706

<151> 2018-10-22

<150> US 62/771,628

<151> 2018-11-27

<150> US 62/813,352

<151> 2019-03-04

<160> 13

<210> 1

<211> 132

<212> PRT

<213> human

<400> 1

Met Leu Gly Val Leu Val Leu Gly Ala Leu Ala Leu Ala Gly Leu Gly

1 　　　 5　　　　　　　　 10　　　　　　　　 15

Phe Pro Asp Pro Cys Phe Arg Ala Asn Cys Glu Tyr Gln Cys Gln Pro

　　　　　 20 　　　　　　　　25 　　　　　　　　 30

Leu Asn Gln Thr Ser Tyr Leu Cys Val Cys Ala Glu Gly Phe Ala Pro

　　　 35 　　　　　　　　 40 　　　　　　　　45

Ile Pro His Glu Pro His Arg Cys Gln Met Phe Cys Asn Gln Thr Ala

50 　　　　　　　　55 　　　　　　　　 60

Cys Pro Ala Asp Cys Asp Pro Asn Thr Gln Ala Ser Cys Glu Cys Pro

65　　　　　　　　 70 　　　　　　　　 75 　　　　　　　　80

Glu Gly Tyr Ile Leu Asp Asp Gly Phe Ile Cys Thr Asp Ile Asp Glu

　　　　　　 85 　　　　　　　　90 　　　　　　　 95

Cys Glu Asn Gly Gly Phe Cys Ser Gly Val Cys His Asn Leu Pro Gly

　　　　　　100 　　　　　　　 105 　　　　　　　 110

Thr Phe Glu Cys Ile Cys Gly Pro Asp Ser Ala Leu Val Arg His Ile

　　 115 　　　　　　　 120 　　　　　　　 125

Gly Thr Asp Cys

　　130

<210> 2

<211> 396

<212> DNA

<213> human

<400> 2

atgcttgggg tcctggtcct tggcgcgctg gccctggccg gcctggggtt ccccgacccg 60

tgcttcagag ccaactgcga gtaccagtgc cagcccctga accaaactag ctacctctgc 120

gtctgcgccg agggcttcgc gcccattccc cacgagccgc acaggtgcca gatgttttgc 180

aaccagactg cctgtccagc cgactgcgac cccaacaccc aggctagctg tgagtgccct 240

gaaggctaca tcctggacga cggtttcatc tgcacggaca tcgacgagtg cgaaaacggc 300

ggcttctgct ccggggtgtg ccacaacctc cccggtacct tcgagtgcat ctgcgggccc 360

gactcggccc ttgtccgcca cattggcacc gactgt 396

<210> 3

<211> 132

<212> PRT

<213> human

<400> 3

Met Leu Gly Val Leu Val Leu Gly Ala Leu Ala Leu Ala Gly Leu Gly

1 5 10 15

Phe Pro Asp Pro Cys Phe Arg Ala Asn Cys Glu Tyr Gln Cys Gln Pro

　　　　　 20 25 30

Leu Asn Gln Thr Ser Tyr Leu Cys Val Cys Ala Glu Gly Phe Ala Pro

35 40 45

Ile Pro His Glu Pro His Arg Cys Gln Met Phe Cys Asn Gln Thr Ala

50 55 60

Cys Pro Ala Asp Cys Asp Pro Asn Thr Gln Ala Ser Cys Glu Cys Pro

65 70 75 80

Glu Gly Tyr Ile Leu Asp Asp Gly Phe Ile Cys Thr Asp Ile Asp Glu

85 90 95

Cys Glu Asn Gly Gly Phe Cys Ser Gly Val Cys His Asn Leu Pro Gly

100 105 110

Thr Phe Glu Cys Ile Cys Gly Pro Asp Ser Ala Leu Ala Arg His Ile

115 120 125

Gly Thr Asp Cys

130

<210> 4

<211> 396

<212> DNA

<213> human

<400> 4

atgcttgggg tcctggtcct tggcgcgctg gccctggccg gcctggggtt ccccgacccg 60

tgcttcagag ccaactgcga gtaccagtgc cagcccctga accaaactag ctacctctgc 120

gtctgcgccg agggcttcgc gcccattccc cacgagccgc acaggtgcca gatgttttgc 180

aaccagactg cctgtccagc cgactgcgac cccaacaccc aggctagctg tgagtgccct 240

gaaggctaca tcctggacga cggtttcatc tgcacggaca tcgacgagtg cgaaaacggc 300

ggcttctgct ccggggtgtg ccacaacctc cccggtacct tcgagtgcat ctgcgggccc 360

gactcggccc ttgcccgcca cattggcacc gactgt 396

<210> 5

<211> 480

<212> PRT

<213> human

<400> 5

Met Leu Gly Val Leu Val Leu Gly Ala Leu Ala Leu Ala Gly Leu Gly

1 5 10 15

Phe Pro Ala Pro Ala Glu Pro Gln Pro Gly Gly Ser Gln Cys Val Glu

20 25 30

His Asp Cys Phe Ala Leu Tyr Pro Gly Pro Ala Thr Phe Leu Asn Ala

35 40 45

Ser Gln Ile Cys Asp Gly Leu Arg Gly His Leu Met Thr Val Arg Ser

50 55 60

Ser Val Ala Ala Asp Val Ile Ser Leu Leu Leu Asn Gly Asp Gly Gly

65 70 75 80

Val Gly Arg Arg Arg Leu Trp Ile Gly Leu Gln Leu Pro Pro Gly Cys

85 90 95

Gly Asp Pro Lys Arg Leu Gly Pro Leu Arg Gly Phe Gln Trp Val Thr

100 105 110

Gly Asp Asn Asn Thr Ser Tyr Ser Arg Trp Ala Arg Leu Asp Leu Asn

115 120 125

Gly Ala Pro Leu Cys Gly Pro Leu Cys Val Ala Val Ser Ala Ala Glu

130 135 140

Ala Thr Val Pro Ser Glu Pro Ile Trp Glu Glu Gln Gln Cys Glu Val

145 150 155 160

Lys Ala Asp Gly Phe Leu Cys Glu Phe His Phe Pro Ala Thr Cys Arg

165 170 175

Pro Leu Ala Val Glu Pro Gly Ala Ala Ala Ala Ala Val Ser Ile Thr

180 185 190

Tyr Gly Thr Pro Phe Ala Ala Arg Gly Ala Asp Phe Gln Ala Leu Pro

195 200 205

Val Gly Ser Ser Ala Ala Val Ala Pro Leu Gly Leu Gln Leu Met Cys

210 215 220

Thr Ala Pro Pro Gly Ala Val Gln Gly His Trp Ala Arg Glu Ala Pro

225 230 235 240

Gly Ala Trp Asp Cys Ser Val Glu Asn Gly Gly Cys Glu His Ala Cys

245 250 255

Asn Ala Ile Pro Gly Ala Pro Arg Cys Gln Cys Pro Ala Gly Ala Ala

260 265 270

Leu Gln Ala Asp Gly Arg Ser Cys Thr Ala Ser Ala Thr Gln Ser Cys

275 280 285

Asn Asp Leu Cys Glu His Phe Cys Val Pro Asn Pro Asp Gln Pro Gly

290 295 300

Ser Tyr Ser Cys Met Cys Glu Thr Gly Tyr Arg Leu Ala Ala Asp Gln

305 310 315 320

His Arg Cys Glu Asp Val Asp Asp Cys Ile Leu Glu Pro Ser Pro Cys

325 330 335

Pro Gln Arg Cys Val Asn Thr Gln Gly Gly Phe Glu Cys His Cys Tyr

340 345 350

Pro Asn Tyr Asp Leu Val Asp Gly Glu Cys Val Glu Pro Val Asp Pro

355 360 365

Cys Phe Arg Ala Asn Cys Glu Tyr Gln Cys Gln Pro Leu Asn Gln Thr

370 375 380

Ser Tyr Leu Cys Val Cys Ala Glu Gly Phe Ala Pro Ile Pro His Glu

385 390 395 400

Pro His Arg Cys Gln Met Phe Cys Asn Gln Thr Ala Cys Pro Ala Asp

405 410 415

Cys Asp Pro Asn Thr Gln Ala Ser Cys Glu Cys Pro Glu Gly Tyr Ile

420 425 430

Leu Asp Asp Gly Phe Ile Cys Thr Asp Ile Asp Glu Cys Glu Asn Gly

435 440 445

Gly Phe Cys Ser Gly Val Cys His Asn Leu Pro Gly Thr Phe Glu Cys

450 455 460

Ile Cys Gly Pro Asp Ser Ala Leu Val Arg His Ile Gly Thr Asp Cys

465 470 475 480

<210> 6

<211> 1440

<212> DNA

<213> human

<400> 6

atgcttgggg tcctggtcct tggcgcgctg gccctggccg gcctggggtt ccccgcaccc 60

gcagagccgc agccgggtgg cagccagtgc gtcgagcacg actgcttcgc gctctacccg 120

ggccccgcga ccttcctcaa tgccagtcag atctgcgacg gactgcgggg ccacctaatg 180

acagtgcgct cctcggtggc tgccgatgtc atttccttgc tactgaacgg cgacggcggc 240

gttggccgcc ggcgcctctg gatcggcctg cagctgccac ccggctgcgg cgaccccaag 300

cgcctcgggc ccctgcgcgg cttccagtgg gttacgggag acaacaacac cagctatagc 360

aggtgggcac ggctcgacct caatggggct cccctctgcg gcccgttgtg cgtcgctgtc 420

tccgctgctg aggccactgt gcccagcgag ccgatctggg aggagcagca gtgcgaagtg 480

aaggccgatg gcttcctctg cgagttccac ttcccagcca cctgcaggcc actggctgtg 540

gagcccggcg ccgcggctgc cgccgtctcg atcacctacg gcaccccgtt cgcggcccgc 600

ggagcggact tccaggcgct gccggtgggc agctccgccg cggtggctcc cctcggctta 660

cagctaatgt gcaccgcgcc gcccggagcg gtccaggggc actgggccag ggaggcgccg 720

ggcgcttggg actgcagcgt ggagaacggc ggctgcgagc acgcgtgcaa tgcgatccct 780

ggggctcccc gctgccagtg cccagccggc gccgccctgc aggcagacgg gcgctcctgc 840

accgcatccg cgacgcagtc ctgcaacgac ctctgcgagc acttctgcgt tcccaacccc 900

gaccagccgg gctcctactc gtgcatgtgc gagaccggct accggctggc ggccgaccaa 960

caccggtgcg aggacgtgga tgactgcata ctggagccca gtccgtgtcc gcagcgctgt 1020

gtcaacacac agggtggctt cgagtgccac tgctacccta actacgacct ggtggacggc 1080

gagtgtgtgg agcccgtgga cccgtgcttc agagccaact gcgagtacca gtgccagccc 1140

ctgaaccaaa ctagctacct ctgcgtctgc gccgagggct tcgcgcccat tccccacgag 1200

ccgcacaggt gccagatgtt ttgcaaccag actgcctgtc cagccgactg cgaccccaac 1260

acccaggcta gctgtgagtg ccctgaaggc tacatcctgg acgacggttt catctgcacg 1320

gacatcgacg agtgcgaaaa cggcggcttc tgctccgggg tgtgccacaa cctccccggt 1380

accttcgagt gcatctgcgg gcccgactcg gcccttgtcc gccacattgg caccgactgt 1440

<210> 7

<211> 480

<212> PRT

<213> human

<400> 7

Met Leu Gly Val Leu Val Leu Gly Ala Leu Ala Leu Ala Gly Leu Gly

1 5 10 15

Phe Pro Ala Pro Ala Glu Pro Gln Pro Gly Gly Ser Gln Cys Val Glu

20 25 30

His Asp Cys Phe Ala Leu Tyr Pro Gly Pro Ala Thr Phe Leu Asn Ala

35 40 45

Ser Gln Ile Cys Asp Gly Leu Arg Gly His Leu Met Thr Val Arg Ser

50 55 60

Ser Val Ala Ala Asp Val Ile Ser Leu Leu Leu Asn Gly Asp Gly Gly

65 70 75 80

Val Gly Arg Arg Arg Leu Trp Ile Gly Leu Gln Leu Pro Pro Gly Cys

85 90 95

Gly Asp Pro Lys Arg Leu Gly Pro Leu Arg Gly Phe Gln Trp Val Thr

100 105 110

Gly Asp Asn Asn Thr Ser Tyr Ser Arg Trp Ala Arg Leu Asp Leu Asn

115 120 125

Gly Ala Pro Leu Cys Gly Pro Leu Cys Val Ala Val Ser Ala Ala Glu

130 135 140

Ala Thr Val Pro Ser Glu Pro Ile Trp Glu Glu Gln Gln Cys Glu Val

145 150 155 160

Lys Ala Asp Gly Phe Leu Cys Glu Phe His Phe Pro Ala Thr Cys Arg

165 170 175

Pro Leu Ala Val Glu Pro Gly Ala Ala Ala Ala Ala Val Ser Ile Thr

180 185 190

Tyr Gly Thr Pro Phe Ala Ala Arg Gly Ala Asp Phe Gln Ala Leu Pro

195 200 205

Val Gly Ser Ser Ala Ala Val Ala Pro Leu Gly Leu Gln Leu Met Cys

210 215 220

Thr Ala Pro Pro Gly Ala Val Gln Gly His Trp Ala Arg Glu Ala Pro

225 230 235 240

Gly Ala Trp Asp Cys Ser Val Glu Asn Gly Gly Cys Glu His Ala Cys

245 250 255

Asn Ala Ile Pro Gly Ala Pro Arg Cys Gln Cys Pro Ala Gly Ala Ala

260 265 270

Leu Gln Ala Asp Gly Arg Ser Cys Thr Ala Ser Ala Thr Gln Ser Cys

275 280 285

Asn Asp Leu Cys Glu His Phe Cys Val Pro Asn Pro Asp Gln Pro Gly

290 295 300

Ser Tyr Ser Cys Met Cys Glu Thr Gly Tyr Arg Leu Ala Ala Asp Gln

305 310 315 320

His Arg Cys Glu Asp Val Asp Asp Cys Ile Leu Glu Pro Ser Pro Cys

325 330 335

Pro Gln Arg Cys Val Asn Thr Gln Gly Gly Phe Glu Cys His Cys Tyr

340 345 350

Pro Asn Tyr Asp Leu Val Asp Gly Glu Cys Val Glu Pro Val Asp Pro

355 360 365

Cys Phe Arg Ala Asn Cys Glu Tyr Gln Cys Gln Pro Leu Asn Gln Thr

370 375 380

Ser Tyr Leu Cys Val Cys Ala Glu Gly Phe Ala Pro Ile Pro His Glu

385 390 395 400

Pro His Arg Cys Gln Met Phe Cys Asn Gln Thr Ala Cys Pro Ala Asp

405 410 415

Cys Asp Pro Asn Thr Gln Ala Ser Cys Glu Cys Pro Glu Gly Tyr Ile

420 425 430

Leu Asp Asp Gly Phe Ile Cys Thr Asp Ile Asp Glu Cys Glu Asn Gly

435 440 445

Gly Phe Cys Ser Gly Val Cys His Asn Leu Pro Gly Thr Phe Glu Cys

450 455 460

Ile Cys Gly Pro Asp Ser Ala Leu Ala Arg His Ile Gly Thr Asp Cys

465 470 475 480

<210> 8

<211> 1440

<212> DNA

<213> human

<400> 8

atgcttgggg tcctggtcct tggcgcgctg gccctggccg gcctggggtt ccccgcaccc 60

gcagagccgc agccgggtgg cagccagtgc gtcgagcacg actgcttcgc gctctacccg 120

ggccccgcga ccttcctcaa tgccagtcag atctgcgacg gactgcgggg ccacctaatg 180

acagtgcgct cctcggtggc tgccgatgtc atttccttgc tactgaacgg cgacggcggc 240

gttggccgcc ggcgcctctg gatcggcctg cagctgccac ccggctgcgg cgaccccaag 300

cgcctcgggc ccctgcgcgg cttccagtgg gttacgggag acaacaacac cagctatagc 360

aggtgggcac ggctcgacct caatggggct cccctctgcg gcccgttgtg cgtcgctgtc 420

tccgctgctg aggccactgt gcccagcgag ccgatctggg aggagcagca gtgcgaagtg 480

aaggccgatg gcttcctctg cgagttccac ttcccagcca cctgcaggcc actggctgtg 540

gagcccggcg ccgcggctgc cgccgtctcg atcacctacg gcaccccgtt cgcggcccgc 600

ggagcggact tccaggcgct gccggtgggc agctccgccg cggtggctcc cctcggctta 660

cagctaatgt gcaccgcgcc gcccggagcg gtccaggggc actgggccag ggaggcgccg 720

ggcgcttggg actgcagcgt ggagaacggc ggctgcgagc acgcgtgcaa tgcgatccct 780

ggggctcccc gctgccagtg cccagccggc gccgccctgc aggcagacgg gcgctcctgc 840

accgcatccg cgacgcagtc ctgcaacgac ctctgcgagc acttctgcgt tcccaacccc 900

gaccagccgg gctcctactc gtgcatgtgc gagaccggct accggctggc ggccgaccaa 960

caccggtgcg aggacgtgga tgactgcata ctggagccca gtccgtgtcc gcagcgctgt 1020

gtcaacacac agggtggctt cgagtgccac tgctacccta actacgacct ggtggacggc 1080

gagtgtgtgg agcccgtgga cccgtgcttc agagccaact gcgagtacca gtgccagccc 1140

ctgaaccaaa ctagctacct ctgcgtctgc gccgagggct tcgcgcccat tccccacgag 1200

ccgcacaggt gccagatgtt ttgcaaccag actgcctgtc cagccgactg cgaccccaac 1260

acccaggcta gctgtgagtg ccctgaaggc tacatcctgg acgacggttt catctgcacg 1320

gacatcgacg agtgcgaaaa cggcggcttc tgctccgggg tgtgccacaa cctccccggt 1380

accttcgagt gcatctgcgg gcccgactcg gcccttgccc gccacattgg caccgactgt 1440

<210> 9

<211> 516

<212> PRT

<213> human

<400> 9

Met Leu Gly Val Leu Val Leu Gly Ala Leu Ala Leu Ala Gly Leu Gly

1 5 10 15

Phe Pro Ala Pro Ala Glu Pro Gln Pro Gly Gly Ser Gln Cys Val Glu

20 25 30

His Asp Cys Phe Ala Leu Tyr Pro Gly Pro Ala Thr Phe Leu Asn Ala

35 40 45

Ser Gln Ile Cys Asp Gly Leu Arg Gly His Leu Met Thr Val Arg Ser

50 55 60

Ser Val Ala Ala Asp Val Ile Ser Leu Leu Leu Asn Gly Asp Gly Gly

65 70 75 80

Val Gly Arg Arg Arg Leu Trp Ile Gly Leu Gln Leu Pro Pro Gly Cys

85 90 95

Gly Asp Pro Lys Arg Leu Gly Pro Leu Arg Gly Phe Gln Trp Val Thr

100 105 110

Gly Asp Asn Asn Thr Ser Tyr Ser Arg Trp Ala Arg Leu Asp Leu Asn

115 120 125

Gly Ala Pro Leu Cys Gly Pro Leu Cys Val Ala Val Ser Ala Ala Glu

130 135 140

Ala Thr Val Pro Ser Glu Pro Ile Trp Glu Glu Gln Gln Cys Glu Val

145 150 155 160

Lys Ala Asp Gly Phe Leu Cys Glu Phe His Phe Pro Ala Thr Cys Arg

165 170 175

Pro Leu Ala Val Glu Pro Gly Ala Ala Ala Ala Ala Val Ser Ile Thr

180 185 190

Tyr Gly Thr Pro Phe Ala Ala Arg Gly Ala Asp Phe Gln Ala Leu Pro

195 200 205

Val Gly Ser Ser Ala Ala Val Ala Pro Leu Gly Leu Gln Leu Met Cys

210 215 220

Thr Ala Pro Pro Gly Ala Val Gln Gly His Trp Ala Arg Glu Ala Pro

225 230 235 240

Gly Ala Trp Asp Cys Ser Val Glu Asn Gly Gly Cys Glu His Ala Cys

245 250 255

Asn Ala Ile Pro Gly Ala Pro Arg Cys Gln Cys Pro Ala Gly Ala Ala

260 265 270

Leu Gln Ala Asp Gly Arg Ser Cys Thr Ala Ser Ala Thr Gln Ser Cys

275 280 285

Asn Asp Leu Cys Glu His Phe Cys Val Pro Asn Pro Asp Gln Pro Gly

290 295 300

Ser Tyr Ser Cys Met Cys Glu Thr Gly Tyr Arg Leu Ala Ala Asp Gln

305 310 315 320

His Arg Cys Glu Asp Val Asp Asp Cys Ile Leu Glu Pro Ser Pro Cys

325 330 335

Pro Gln Arg Cys Val Asn Thr Gln Gly Gly Phe Glu Cys His Cys Tyr

340 345 350

Pro Asn Tyr Asp Leu Val Asp Gly Glu Cys Val Glu Pro Val Asp Pro

355 360 365

Cys Phe Arg Ala Asn Cys Glu Tyr Gln Cys Gln Pro Leu Asn Gln Thr

370 375 380

Ser Tyr Leu Cys Val Cys Ala Glu Gly Phe Ala Pro Ile Pro His Glu

385 390 395 400

Pro His Arg Cys Gln Met Phe Cys Asn Gln Thr Ala Cys Pro Ala Asp

405 410 415

Cys Asp Pro Asn Thr Gln Ala Ser Cys Glu Cys Pro Glu Gly Tyr Ile

420 425 430

Leu Asp Asp Gly Phe Ile Cys Thr Asp Ile Asp Glu Cys Glu Asn Gly

435 440 445

Gly Phe Cys Ser Gly Val Cys His Asn Leu Pro Gly Thr Phe Glu Cys

450 455 460

Ile Cys Gly Pro Asp Ser Ala Leu Val Arg His Ile Gly Thr Asp Cys

465 470 475 480

Asp Ser Gly Lys Val Asp Gly Gly Asp Ser Gly Ser Gly Glu Pro Pro

485 490 495

Pro Ser Pro Thr Pro Gly Ser Thr Leu Thr Pro Pro Ala Val Gly Leu

500 505 510

Val His Ser Gly

515

<210> 10

<211> 1548

<212> DNA

<213> human

<400> 10

atgcttgggg tcctggtcct tggcgcgctg gccctggccg gcctggggtt ccccgcaccc 60

gcagagccgc agccgggtgg cagccagtgc gtcgagcacg actgcttcgc gctctacccg 120

ggccccgcga ccttcctcaa tgccagtcag atctgcgacg gactgcgggg ccacctaatg 180

acagtgcgct cctcggtggc tgccgatgtc atttccttgc tactgaacgg cgacggcggc 240

gttggccgcc ggcgcctctg gatcggcctg cagctgccac ccggctgcgg cgaccccaag 300

cgcctcgggc ccctgcgcgg cttccagtgg gttacgggag acaacaacac cagctatagc 360

aggtgggcac ggctcgacct caatggggct cccctctgcg gcccgttgtg cgtcgctgtc 420

tccgctgctg aggccactgt gcccagcgag ccgatctggg aggagcagca gtgcgaagtg 480

aaggccgatg gcttcctctg cgagttccac ttcccagcca cctgcaggcc actggctgtg 540

gagcccggcg ccgcggctgc cgccgtctcg atcacctacg gcaccccgtt cgcggcccgc 600

ggagcggact tccaggcgct gccggtgggc agctccgccg cggtggctcc cctcggctta 660

cagctaatgt gcaccgcgcc gcccggagcg gtccaggggc actgggccag ggaggcgccg 720

ggcgcttggg actgcagcgt ggagaacggc ggctgcgagc acgcgtgcaa tgcgatccct 780

ggggctcccc gctgccagtg cccagccggc gccgccctgc aggcagacgg gcgctcctgc 840

accgcatccg cgacgcagtc ctgcaacgac ctctgcgagc acttctgcgt tcccaacccc 900

gaccagccgg gctcctactc gtgcatgtgc gagaccggct accggctggc ggccgaccaa 960

caccggtgcg aggacgtgga tgactgcata ctggagccca gtccgtgtcc gcagcgctgt 1020

gtcaacacac agggtggctt cgagtgccac tgctacccta actacgacct ggtggacggc 1080

gagtgtgtgg agcccgtgga cccgtgcttc agagccaact gcgagtacca gtgccagccc 1140

ctgaaccaaa ctagctacct ctgcgtctgc gccgagggct tcgcgcccat tccccacgag 1200

ccgcacaggt gccagatgtt ttgcaaccag actgcctgtc cagccgactg cgaccccaac 1260

acccaggcta gctgtgagtg ccctgaaggc tacatcctgg acgacggttt catctgcacg 1320

gacatcgacg agtgcgaaaa cggcggcttc tgctccgggg tgtgccacaa cctccccggt 1380

accttcgagt gcatctgcgg gcccgactcg gcccttgtcc gccacattgg caccgactgt 1440

gactccggca aggtggacgg tggcgacagc ggctctggcg agcccccgcc cagcccgacg 1500

cccggctcca ccttgactcc tccggccgtg gggctcgtgc attcgggc 1548

<210> 11

<211> 516

<212> PRT

<213> human

<400> 11

Met Leu Gly Val Leu Val Leu Gly Ala Leu Ala Leu Ala Gly Leu Gly

1 5 10 15

Phe Pro Ala Pro Ala Glu Pro Gln Pro Gly Gly Ser Gln Cys Val Glu

20 25 30

His Asp Cys Phe Ala Leu Tyr Pro Gly Pro Ala Thr Phe Leu Asn Ala

35 40 45

Ser Gln Ile Cys Asp Gly Leu Arg Gly His Leu Met Thr Val Arg Ser

50 55 60

Ser Val Ala Ala Asp Val Ile Ser Leu Leu Leu Asn Gly Asp Gly Gly

65 70 75 80

Val Gly Arg Arg Arg Leu Trp Ile Gly Leu Gln Leu Pro Pro Gly Cys

85 90 95

Gly Asp Pro Lys Arg Leu Gly Pro Leu Arg Gly Phe Gln Trp Val Thr

100 105 110

Gly Asp Asn Asn Thr Ser Tyr Ser Arg Trp Ala Arg Leu Asp Leu Asn

115 120 125

Gly Ala Pro Leu Cys Gly Pro Leu Cys Val Ala Val Ser Ala Ala Glu

130 135 140

Ala Thr Val Pro Ser Glu Pro Ile Trp Glu Glu Gln Gln Cys Glu Val

145 150 155 160

Lys Ala Asp Gly Phe Leu Cys Glu Phe His Phe Pro Ala Thr Cys Arg

165 170 175

Pro Leu Ala Val Glu Pro Gly Ala Ala Ala Ala Ala Val Ser Ile Thr

180 185 190

Tyr Gly Thr Pro Phe Ala Ala Arg Gly Ala Asp Phe Gln Ala Leu Pro

195 200 205

Val Gly Ser Ser Ala Ala Val Ala Pro Leu Gly Leu Gln Leu Met Cys

210 215 220

Thr Ala Pro Pro Gly Ala Val Gln Gly His Trp Ala Arg Glu Ala Pro

225 230 235 240

Gly Ala Trp Asp Cys Ser Val Glu Asn Gly Gly Cys Glu His Ala Cys

245 250 255

Asn Ala Ile Pro Gly Ala Pro Arg Cys Gln Cys Pro Ala Gly Ala Ala

260 265 270

Leu Gln Ala Asp Gly Arg Ser Cys Thr Ala Ser Ala Thr Gln Ser Cys

275 280 285

Asn Asp Leu Cys Glu His Phe Cys Val Pro Asn Pro Asp Gln Pro Gly

290 295 300

Ser Tyr Ser Cys Met Cys Glu Thr Gly Tyr Arg Leu Ala Ala Asp Gln

305 310 315 320

His Arg Cys Glu Asp Val Asp Asp Cys Ile Leu Glu Pro Ser Pro Cys

325 330 335

Pro Gln Arg Cys Val Asn Thr Gln Gly Gly Phe Glu Cys His Cys Tyr

340 345 350

Pro Asn Tyr Asp Leu Val Asp Gly Glu Cys Val Glu Pro Val Asp Pro

355 360 365

Cys Phe Arg Ala Asn Cys Glu Tyr Gln Cys Gln Pro Leu Asn Gln Thr

370 375 380

Ser Tyr Leu Cys Val Cys Ala Glu Gly Phe Ala Pro Ile Pro His Glu

385 390 395 400

Pro His Arg Cys Gln Met Phe Cys Asn Gln Thr Ala Cys Pro Ala Asp

405 410 415

Cys Asp Pro Asn Thr Gln Ala Ser Cys Glu Cys Pro Glu Gly Tyr Ile

420 425 430

Leu Asp Asp Gly Phe Ile Cys Thr Asp Ile Asp Glu Cys Glu Asn Gly

435 440 445

Gly Phe Cys Ser Gly Val Cys His Asn Leu Pro Gly Thr Phe Glu Cys

450 455 460

Ile Cys Gly Pro Asp Ser Ala Leu Ala Arg His Ile Gly Thr Asp Cys

465 470 475 480

Asp Ser Gly Lys Val Asp Gly Gly Asp Ser Gly Ser Gly Glu Pro Pro

485 490 495

Pro Ser Pro Thr Pro Gly Ser Thr Leu Thr Pro Pro Ala Val Gly Leu

500 505 510

Val His Ser Gly

515

<210> 12

<211> 1548

<212> DNA

<213> human

<400> 12

atgcttgggg tcctggtcct tggcgcgctg gccctggccg gcctggggtt ccccgcaccc 60

gcagagccgc agccgggtgg cagccagtgc gtcgagcacg actgcttcgc gctctacccg 120

ggccccgcga ccttcctcaa tgccagtcag atctgcgacg gactgcgggg ccacctaatg 180

acagtgcgct cctcggtggc tgccgatgtc atttccttgc tactgaacgg cgacggcggc 240

gttggccgcc ggcgcctctg gatcggcctg cagctgccac ccggctgcgg cgaccccaag 300

cgcctcgggc ccctgcgcgg cttccagtgg gttacgggag acaacaacac cagctatagc 360

aggtgggcac ggctcgacct caatggggct cccctctgcg gcccgttgtg cgtcgctgtc 420

tccgctgctg aggccactgt gcccagcgag ccgatctggg aggagcagca gtgcgaagtg 480

aaggccgatg gcttcctctg cgagttccac ttcccagcca cctgcaggcc actggctgtg 540

gagcccggcg ccgcggctgc cgccgtctcg atcacctacg gcaccccgtt cgcggcccgc 600

ggagcggact tccaggcgct gccggtgggc agctccgccg cggtggctcc cctcggctta 660

cagctaatgt gcaccgcgcc gcccggagcg gtccaggggc actgggccag ggaggcgccg 720

ggcgcttggg actgcagcgt ggagaacggc ggctgcgagc acgcgtgcaa tgcgatccct 780

ggggctcccc gctgccagtg cccagccggc gccgccctgc aggcagacgg gcgctcctgc 840

accgcatccg cgacgcagtc ctgcaacgac ctctgcgagc acttctgcgt tcccaacccc 900

gaccagccgg gctcctactc gtgcatgtgc gagaccggct accggctggc ggccgaccaa 960

caccggtgcg aggacgtgga tgactgcata ctggagccca gtccgtgtcc gcagcgctgt 1020

gtcaacacac agggtggctt cgagtgccac tgctacccta actacgacct ggtggacggc 1080

gagtgtgtgg agcccgtgga cccgtgcttc agagccaact gcgagtacca gtgccagccc 1140

ctgaaccaaa ctagctacct ctgcgtctgc gccgagggct tcgcgcccat tccccacgag 1200

ccgcacaggt gccagatgtt ttgcaaccag actgcctgtc cagccgactg cgaccccaac 1260

acccaggcta gctgtgagtg ccctgaaggc tacatcctgg acgacggttt catctgcacg 1320

gacatcgacg agtgcgaaaa cggcggcttc tgctccgggg tgtgccacaa cctccccggt 1380

accttcgagt gcatctgcgg gcccgactcg gcccttgccc gccacattgg caccgactgt 1440

gactccggca aggtggacgg tggcgacagc ggctctggcg agcccccgcc cagcccgacg 1500

cccggctcca ccttgactcc tccggccgtg gggctcgtgc attcgggc 1548

<210> 13

<211> 21

<212> DNA

<213> Artificial sequence

<220>

<223> Artificial sequence description: synthesis of DNA

<400> 13

aatgtggcgg gcaagggccg a 21

Claims

1. A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients whose international normalized ratio, INR, immediately before administration is greater than 1.4.

2. The medicament of claim 1, wherein the medicament is for administration of a platelet count of greater than 30,000/mm immediately prior to administration³Is administered to the patient.

3. A medicament as claimed in claim 1 or claim 2, wherein the medicament is for administration to a patient whose immediate pre-administration value of thrombin-antithrombin complex (TAT) is 10ng/mL or greater.

4. A medicament as claimed in any one of claims 1 to 3, wherein the medicament is for administration to a subject having a platelet count of greater than 30,000/mm immediately prior to administration³And the patient having a Sofa score of 11 or less.

5. A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose value of thrombin-antithrombin complex (TAT) immediately before administration is 10ng/mL or more.

6. A medicament for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to the patient whose prothrombin fragment 1+2, i.e. F1+2, value immediately before administration is greater than 229 pmol/L.

7. A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose protein C activity value immediately before the administration is 40% or less.

8. A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients whose antithrombin III (AT III) activity value immediately before administration is less than 70%.

9. A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients whose value of microparticles, i.e., MP, immediately before administration is greater than 10 nm.

10. A medicament for the treatment and/or amelioration of patients with sepsis, which comprises thrombomodulin as an active ingredient, characterized in that the medicament is for administration to such patients having an APACHE II score of less than 35 immediately before administration.

11. A drug for the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient having organ dysfunction of 1 or more and 3 or less immediately before the administration.

12. The medicament of claim 1 or 2, wherein the medicament is for administration to the patient having 1 or more and 3 or less organ dysfunctions immediately prior to administration.

13. A drug for use in the treatment and/or amelioration of a sepsis patient, which comprises thrombomodulin as an active ingredient, characterized in that the drug is for administration to the patient whose D-dimer value immediately before administration is 3,500ng/mL or more.

14. The medicament of claim 1 or 2, wherein the medicament is for administration to the patient having a value of 3,500ng/mL or more of D-dimer immediately prior to administration.

15. The medicament of claim 1 or 2, wherein the medicament is for administration to the patient having a prothrombin fragment 1+2, F1+2, value greater than 229pmol/L immediately prior to administration.

16. A medicament as claimed in claim 1 or claim 2, wherein the medicament is for administration to the patient having a protein C activity value immediately prior to administration of less than 40%.

17. The medicament of claim 1 or 2, wherein the medicament is for administration to the patient having an antithrombin III (AT III) activity value of less than 70% immediately prior to administration.

18. A medicament as claimed in claim 1 or claim 2, wherein the medicament is for administration to the patient having a pre-administration particulate (MP) value of greater than 10 nm.

19. The medicament of claim 1 or 2, wherein the medicament is for administration to the patient having an APACHE II score of less than 35 immediately prior to administration.

20. The drug according to claim 1 or 2, wherein the drug is used for intravenous administration of 0.005mg/kg to 1mg/kg of the thrombomodulin at a frequency of 1 time per day for at least 4 consecutive days to a sepsis patient with blood coagulation disorder.

21. The medicament according to any one of claims 1 to 20, wherein the administration is immediately before followed within 24 hours from the start of administration of thrombomodulin.